HomeMy WebLinkAbout380 Wicks Rd
Date: 08/13/02
Transaction(s):
Town Of South old
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 16469
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
Receipt#:
Total Paid:
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16469
Subtotal
$45.00
$45.00
InternallD: 61407
Permit No.
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCA V A TION AND REPAIR
Ref.#T100192140
APPLICATION IS HEREBY made to the Superintendent of Highways urthe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 orthe Code or 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 orthe
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVlLLE. NY 11801
Name of Applicant Address
2) 380 Wicks Road. New Suffolk
Name of Owner of Premises
Address
3) Ouen & restore a bell hole on the s/s Daved area aODrox. 165' wlo New Suffolk La.. New Suffolk
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction louted within 75 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.
Other Tr
Signature 0 Appli nt
07-26-02
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
by the Towu Clerk.
6) Tax Map: Section
,Block
. Lot
7) Starting Date:
Completion Date:
8) Work Schedule:
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
Tl00192140
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Departtnent:
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 anolications and oermits: Basic AooIication Fee.............. ... $25.00
AI. -L-/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 I.[ ~ $10.00
I.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. ~ $30.00
_I.[@$0.30~$
Additional
D. Excavations 5' in depth and over:
0- I 00 I.[ ~ $50.00
I.[@ $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.
Peter W. Harris
R-/it?'..?
Received by the Town Clerk
Permit Issued ~ I 3/0 2.-
r;/ ~d <--
Date
Permit No.
o?06-'
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 20f3
BU GAS DESIGN PATCH TEL:5!6 7585136
KEYSPAtV~A.J"
REQUEST FOR STREET OPENING PERMIT
"JGlI.-26'02(FRII10:10
FO<ll11,4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W,O./PA
NO.
REQUESTED
BY
ApPROVED
SKETCH
o STATE
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~ ,I DEPARTMENT
0/.1 ...)bllu72- GASCONSTR. L.'z.)
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