HomeMy WebLinkAbout2810 Westphalia Ave
Town Of South old
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 08/13/02
Receipt#:
16418
1 Permits
Check#: 16418
Total Paid:
Subtotal
$45.00
$45.00
Transaction(s):
y
Lr ~O
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
Internal 10: 61404
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLlCATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100185078
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of the 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 Inspedlons ortbe
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 2810 Westohalla Ave.. Mattituck
Name of Owner of Premises
Address
3) WestDhalia Ave. - hellhole sfs Daved area aDDrox. 130' slo Deer Dr.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*Jf yes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Tr
ofAp
7-09-02
Date
5) a) Attach plot plan showiDg 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 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
Tl00185078
12) Insurance Covera.e: (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 $50,000 property damage.
13) Security:
a)
b)
Surety Bond
of$
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 Coonections excavations @ $20.00 = $ 20.00
No.
A2. _/ Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
1.f.@$0.1O=$
Additional
C. Excavations IS" in depth to 5' in depth:
0-100 I.f. = $30.00
_I.f. @ $0.30 = $
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
1.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 $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.
syiZ
o.ce
Received by the Town Clerk r cf' ~ 2-
'dL ~ n.te
Permit Issued <?, iO 1--' Permit No.
c:2tJ 2..----
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
JUL. '~"o4"02 (THU) 12: 13
P. 002
BU GAS DESIGN PATCH TEL:516 7585136
KEYSP AN/c;;A.J'
REQUEST FOR STREET OPENING PERMIT
O SUFFOLK
COUNTY
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NO.
LOCATION
REASON FOR
OPENING
W,OJPA'
NO.
REQUESTED
BY
APPROVED
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