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Home My WebLink About2595 Peconic Ln . Date: 05/13/03 Transaction(s): Name: Clerk ID: L1NDAC Town Of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * 1 Permits Check#: 1441 * Key, Span Energy - Gas Cont Dept 175 E Old County Rd Hicksville, NY 11801 Receipt#: Total Paid: J61 1441 Subtotal $45.00 $45.00 InternallD: 74904 F~E No.728 05/09 '03 13:15 ID: FAX: PAGE 2/ 5 - -<N.od;SL }lile No. TOWN OF SOUTHOLD llIGHWA Y DEPARTMENT Peeonie Lane Peconlc, New York 11958 (631) 765-3140 APPLICATlONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR BMEllGEN'CY Ret.#TI00283176 API'UCATION IS m:uBV _de... tbe S.peri.l...denl .fWgllw.y..f ,be Tow. .f So.lbold l.r Ibe Iu..... .f .. &navali.. Permil p......II. Cb.pler 83 .flbe C.de.ClIle T.w..f So.lbol'" S.ff.lk C'..ll', New Vorl<, ..d otbe.- .pplieal>\e 1aWli, ....u.u.- or reguloli...lor Ibe "..".Iia. be..... de&<ril>tcl. Tbe .ppli...togreeo ... .....ply with oil applicable lawS, .rdi....... <odes ..d rtgulatious, o.d ... pttmll ..lb.rIzed ios,.."''' Iv mak< .......ry i..pted... oflbe ioblite. Print or Tvne I) KEYSl'AN ENERGY _GAS CONSTa. DEPT. -175 Eo OLD COUNTRY RD- - mCKSVILLE. NY 11801 N.... of Appli<aat Addr'" Z) ZS9S Pec.ODi~ Lan~ Pec::onie Name of Own<< of Premi.ies Addr... J) puonic Lane- beIJbolew/s PTaSS area aooroX. 800' nlo Carron Ave.. Pee-ante. to tuhe a gS service Work ll<seriplio. ..el Locatio. (Sit'" N.mber, Hamlet, Cre.. SIroeI) (0) Is .......<Ii4>.I...1ed within 7. feet ollidal wedaDd<? 'V.. N. - "- -If yts. otb.- Town permi'Ui may be rtq"'lred. 4) a.Uller', Lice... No. PI.IIIb.r', Llu..e No. E1ectrie\ao" Lie.." No. 's License No. Signature of pli n 0s-ll9-03 Date S) a) Attach plot p\all'bowing location 01 p",posed excavation and .elaliollibip 10 adjolnl.g premis.. or p.blle....eets or IU'..... and giving a detallecl d.scription of Iayoul of enavali.n. b) Attacb aU giber D_ry permits aod IIUDS.' for Ibis project. c) Work covered by iblo appllcatloD may nol commence before 1.....Dee 01 a Higbway Excavation Pencil by ibe Town Clerk. 6) Tax Map: Section 7) Starting Dale: 8) W.rk Scbmlnle: ,Block ,Lol Completio. nate: lI!.m Comuletion Dale Ext:ava$loa 60......... ......... ......... ...... ........ ". .0. ....... o. ....... ........ Fadlity I..tallalio.- .......... ........ ....,.. ............ .................. ""N' lla<kliU'" COmp.eliO............... .-........................ ........- -....... p.vemo.1 Repla<om<llt................. ..-........ ...... - -. ............. --..... 9) UDder wblcb a.tbority i,the application maele: 10) E,tlmaled Coot 01 Proposed Work: $ 11) aemarks: ll-39 Plgel of3 FILE No ..728 05/09 '03 13: 16 ID: FAX: PAGE 3/ 5 Tl00283176 12) Insurance Covelll~e: (Allach Copy) a) Insurance Company: b) Polic:y# 0) Stale whClhcr policy of certification on file wilb the Highway Deportment: d) Coverage required extended to the Town: flodily injury and properly damage: S3oo,000Ili5oo,000 Ilodily Il\iury, and S50,000 property damage, 13) Security: a) SUl"elY Ilood or Ceoified Cheek oU b) Maintenance Bonded provided: 2 years or provided in the total amount 3 years 14) Fees for apolications and nermi,,: Basi. ADDUcation Fee ...............-- $25.00 A I. -.l-lService ConneetiOns excavation' @ S20,00 = $ 20.00 No, A2, -'Additional Excavations sarne ,ervice @ S10.oo ~ S No, Il. Excavations 18" in deplll or less: ()..IOO I.f. = SIO,oo 1.f.@SO.IO=S Additi~ C. Excavations IS" in deplllto 5' in depth: ()..IOO (,f, = S30,00 = _I.f. @$0.30 = Additional D, Excavation. S' in depth and over: 0-100 I,r. ~ S50.oo 1.f. @ SO.50 = S Additi~ E. No. Utility Repair Excavations @ S 10.00 = ~ Repairs same SClVice @S5.oo= S Additional F. Notice to public utilities proof must b. provided and anached to thi, application prior to issuance of permit. . . . TOTAL COST $45.00 AutharizatiOl\ is htccby guntc:d to Ihe Town Clerk of the To'M'l of Soulhold to i:mac ..Highway Excavation Pcmrit to: KEYS' AN ENERGY nEUVERY in accordance will> tIli. application. R.ereived by lIIe Town Clerk ...s- J/.J /0 -' Permit Issued oj;" / () )..- Pal< Permit No. I , ~Sl ~: pcnnitexpirell one (1) year trmn D:.ne oflssuance. No wock to stan without 48 hoLlrnotice to the Superintent:knl ot Hish\N'3}'li. P'mnit must be availablo for Uaspection. J)-3' f.t.20f3 ~ILE No,728 05/09 '03 13:16 ID: FAX: PAGE 5/ 5 NO. LpOAt1ON ~R , WCtA l'laaUE8TED ' .. BY . APPROVED " SkETCH 10:23 BU GAS DESIGN PATCH TI:;L:~lb I~~~IJO r, uu< N:Tet'AN/6A,!, ' , ' " ReQUEST FpRSTAEEJ: OPENING PER~' . ,0 ~A11' ,tJ ~~' , '0 =:f:' . [Xl ~f~~t.l , UI& Till" " , NO. 0. 2S3 I ? " '~1' /z..f;tJ3 " . H/b, ,;" 'M a MAY, -08' 03 ('t:HUI fOf11M -&~ " " ' ~/}l:J '* /I)(J -S~ ~ 1- ' N " " . , ~' t" ' ,'" l::) ,~, ,..: " ,~ '~ . , ' ,~t. U\ 'f{ ~ - " L ,1. " "~~ , , " I~ 11." Iw-r L.--~----- ..c.. ' '-r:Z .' ~, -. . " ,'I' " !'>. ' W, - ' , : ,- .; 'RU$H' "-:" " , ' , , " ' C. A t(lD/L. ,w~ "