HomeMy WebLinkAbout43715 Horton Ln
Date: 06/02/03
Transaction(s):
Name:
Clerk ID: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 1519
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
I
,
/
c;t
Receipt#:
Total Paid:
1519
Subtotal
$75.00
$75.00
InternallD: 76169
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 EXCAVATION AND REPAIR
Ref.#T100271648
APPLICATION IS HEREBY made to the Superintendent of Highways or the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 ortbe Code orthe 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 oftbe
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 43715 Horton Lane, Sonthold
Name of Owner of Premises
Address
Horton Lane - bellhole and 80' trench in the w/s e:rass area nlo Middle Road. Southord to install a e:as main and
e:as 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) Builder's License No.
Plumber's License No.
Electrician's License No.
gnature of Ap
03-27-03
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 Comnletion 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
Tl00271648
.
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 aoohcatlOTIS and oenruts: Basic ADDlication Fee.............. ... $25.00
AI. _I~Service Connections excavations@ $20.00 ~ $20.00
A2. _/Additional Excavations same service@$1O.00=$
No.
B. Excavations 18" in depth or less:
0-100 l.f. ~ $10.00-
If @ $0.10 ~
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. ~ $30.00
_I.f.@SO.30~
Additional
D. Excavations 5' in depth and over:
0-100 l.f. ~ $50.00
l.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
permit.
* * *
TOTAL COST $75.00
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.
~?~;iS
I ate
Received by the Town Clerk .s /.3 0/ oj
Permit Issued h / ,;z,j 0 3
.
Permit No.
OlSr
Date
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
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