HomeMy WebLinkAbout55 Wells Rd
Date: 07/10/02
Transaction(s):
.~ ; ~' '
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16318
Total Paid:
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
16318
Subtotal
$45.00
$45.00
InternallD: 59352
Permit No.
~."''''~
~
FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#Tl00178817
APPLICATION IS HEREBY made to the Superintendent of Highways oftbe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of the 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 witb all
applicable laws, ordinances, codes and regulations, and to permit authorized inspectors to make necessary inspections of the
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 55 Wells Road. Laurel
Name of Owner of Premises
Address
3) Wells Rd - Hellhole w/s oaved area 8oorox. 100' slo Alba Drive. Laurel. for a 2as service to a new house
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? "'Yes No
*Ifyes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other
ofAp
6-20-02
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 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
Tl00178817
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 $50,000 property damage.
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic AODlication Fee................. $25.00
AI. ~/Service Connections excavations @ $20.00 = $ 20.00
No.
A2. ----..! Additional Excavations same service @ $1 0.00 ~ $
No.
B. Excavations 18" in depth or less:
0-100 I.f. ~ $10.00
l.f. @ $0.1O~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. ~ $30.00
_l.f.@$0.30~$
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
I.f. @ $0.50 ~ $
Additional
Utility Repair Excavations @ $1 0.00 ~ $
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
permit.
. . .
TOTAL COST $45.00
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.
Received by the Town Clerk
7- q~- 02.-
SUPERINTENDENT OF HIGHWAYS
TZ;~~~
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Date
Permit No.
/W
Permit Issued
7 -ftP-O 2.-
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 2 of3
JUN. -18' O"2ITUE) 08: 11
BU GAS DESIGN PATCH TEL:516 i585136
KEYSPAN/t;:A.s'
REQUEST FOR STREET OPENING PERMIT
P. 002
FCoGll1.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING nt." rJ
W,O./PA
NO.
REQUESTED . J ? JI _ DEPARTMENT
BY 0;.1 ..Jt:dfti-7Z- GAS CONSm. L...r,)
o STATE
o
; D SUFFOLK r:71
. COUNTY IlU
. APPROVED
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