HomeMy WebLinkAbout1025 Gull Pond Ln
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date; 06/25/02
Receipt#:
16317
1 Permits
Check#: 16317
Total Paid:
Subtotal
$45.00
$45.00
Transaction(s):
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
IntemallD; 57615
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Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
FileNo.
.
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100173109
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuaDf~e of
an Excavation Permit pursuant to Chapter 83 or the Code of the Town ofSoutbold, Suffolk County. New York, and other
applicable laws, ordinances or regulations for the excavation herein described. The applicant agrees to comply with an
applicable laws, ordinances, codes and regulations, and to permit authorized Inspedors to make n~essary inspections ortbe
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - H1CKSVILLE. NY 11801
Name of Applicant Address
2) 1025 Gull Poud Lane, Greenport
Name of Owner of Premises
Address
3) ODeD & restore a bell hole on the w/s 2rass area aoorox. 100' slo Main Rd.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
ignatu of Appli
06-19-02
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.
h) 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
by the Town Clerk.
6) Tax Map: Section
. Block
. Lot
7) Starting Date:
Completion Date:
8) Work Scheduie:
Phase Comoletion Date
Excavation.......... ................ ........................ .......................
Facility Installation.. ......... ... ..... .... ........ .... ..... .... ..... ....... .......
Backfill & Compaction.........................................................
Pavement Replacement.......... ........................................ .......
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: S
II) Remarks:
D-39
Page 1 of3
Tl00173109
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 ADDlication Fee ................. $25.00
AI. ~Service Connections 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. = $10.00
I.f. @$O.IO=$
Additional
C. Excavations 18" in depth to 5' in depth:
0- I 00 1.f. = $30.00
_1.f.@$0.30=$
Additional
D. Excavations 5' in depth and over:
0- 100 1.f. = $50.00
I.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 afthe Town of Southald to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Peter W. Harris
Received by the Town Clerk &7/ d-:>fi.z...;
/ J Date
Permit Issued ~I <><5,1 () ^-- Permit No.
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.
Date
/9(..
D-39
Page 2 0(3
JUN.-06'02(THU) 08:41
SU GAS DESIGN PATCH
TEL:516 7585136
P. 002
KEYSPAN/tfA.r
REQUEST FOR STREET OPENING PERMIT
FC-S"'.4
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.OJPA
NO.
ReQUESTED
BY
. APPROVED
D STATE
D SUFFOLK r.7l
COUNTY JlU
0;'; ..s;: u7Z...
DEPARTMENT
GAS CONSTR.
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