HomeMy WebLinkAbout455 Stillwater Ave
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Date: 08/13/02
Transaction(s):
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16463
Total Paid:
J
>>- dO
Name:
Key, Span Energy - Gas Cant Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
16463
Subtotal
$45.00
$45.00
InternallD: 61406
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100189988
APPLICATION ]S HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 ortbe Code ortbe 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 or 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) 455 Stillwater Ave.. Cutchol!ue
Name of Owner of Premises
Address
3) hellhole s/s l!rass area approx. 725' elu/el of Peauash Avenue
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S feet oftidal wetlands? *Yes No
*Ifyes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other T
eofAp
07-22-02
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 layont 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 Town 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:
P-39
Page 1 of3
,
Tl00189988
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 property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
13) Securitv:
a)
b)
Surety Bond
01$
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.
Al. ------1 Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 l.f. ~ $10.00
1.1. @ $0.10 ~ $
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
1.1. @ $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 South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk 'i?/ ifo :l--
J / Date
rr-/fO/1:; 2.0
Pennit Issued
Pennit No.
CloLf
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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BU GAS DESIGN PATCH TEL:5!6 i585136
KEYSPAN/~A.!
REQUEST FOR STREET OPENING PERMIT
P. 004
dUlr. -22' 02(MON) 08:45
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PERMIT
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LOCATION
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