HomeMy WebLinkAbout795 Westwood Ln
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Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 08/13/02
Receipt#:
16417
1 Permits
Check#: 16417
Total Paid:
Subtotal
$88.80
$88.80
Transaction(s):
~ ')01
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
IntemallD: 61400
Permit NOoJ () /
FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
of'~
-
APPLICATIONIPERMIT FOR HIGHWAY EXCA V A TION AND REPAIR
Ref.#TlOOI85525
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 orthe Code of the Town of South old, 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 inspedors to make necessary Inspections ofthe
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 795 Westwood Lane, Greenport
Name of Owner of Premises
Address
3) Westwood Lane - bellhole and a 146' trench south in the wls grass area approx. 106' slo
lulet Pond Rd., Greenport
4) Work Description and Location (Street Number, Hamlet, Cross Street)
<a) Is construt'tion 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.
Other Tr
eofAp
07-10-02
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 tbis application may not commence before issuance of a Highway Excavation Permit
by tbe Town Clerk.
6) Tax Map: Section
,Block
. Lot
7) Starting Date:
Completion Date:
8) Work Scbedule:
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
Tl00185525
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 $50,000 property damage.
13) Security:
a)
provided in the total amount
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
2 years or
3 years
14) Fees for anolications and nermits: Basic Application Fee................. $25.00
AI. _1---!Service Connections excavations@$20.00= $20.00
A2. -"Additional Excavations same service@$10.00=$
No.
B. Excavations 18" in depth or less:
0-100 J.f. = $10.00
1.f.@$0.1O=$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I. f. = $30.00
46 I.f. @ $0.30 = $13.80
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
1.f.@$0.50=$
Additional
Utility Repair Excavations @ $10.00 = $
E.
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
pennit.
. . .
TOTAL COST $88.80
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.
Received by the Town Clerk 'g / 8' 10 z.
(';/). I Da
Permit Issued f; / I J (;> 0 Permit No.
t ,
0201
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
.
JUL,-!0'02(WED) 08:34
BU GAS DESIGN PATCH TEL:516 7585136
KEYSPAN/d'AJ
REQUEST FOR STREET OPENING PERMIT
FOolIl11A
o STATE
NO,
, L,OCATION
CEPARl'M
Hu1i. GASCONSTR, "lloltr.
APPROVED
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