HomeMy WebLinkAbout290 Gillette Dr
Date: 06/25/02
Transaction(s):
1 Permits
Cash#: 16317
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
q
Receipt#:
Total Paid:
16317
Subtotal
$45.00
$45.00
Intem.IID: 57613
Permit No.
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
--
APPLICATION/PERMIT FOR IDGHW AY EXCAVATION AND REPAIR
Ref.#T100174044
APPLICATION IS HEREBY made to the Superintendent of Highways of tbe Town of Southold for tbe issuance of
an Excavation Permit pursuant to Chapter 83 ortbe Code oftbe Town of Southold, Suffolk County, New York, and otber
applicable laws, ordinanC'es or regulations for tbe excavation herein described. The applicant agrees to comply with all
applicable laws, ordinances, codes and regulations, and to permit authorized inspectors to make ne<:essary insped:ions of the
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVlLLE. NY 11801
Name of Applicant Address
2) 290 Gillette Drive, East Marion
Name of Owner of Premises
Address
3) ODeD & restore a bell hole 00 the tIs Ilrass area BDDrox. 225' slo Main Rd.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S 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.
e of Ap
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.
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
by the Town Clerk.
6) Tax Map: Section
. Block
,Lot
7) Starting Date:
Completion Date:
8) Work Schedule:
Phase ComoletioD 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
TI00174044
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 applications and permits: Basic Application Fee ................. $25.00
AI. ~Service Connections excavations@ $20.00 ~ $ 20.00
No.
A2. _I Additional Excavations same service @ $ I 0.00 ~ $
No.
B. Excavations 18" in depth or less:
0- 100 1.f. ~ $ 10.00
1.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0- 100 1.f. ~ $30.00
_1.f.@$0.30~$
Additional
D. Excavations 5' in depth and over:
0- 100 1.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.
Received by the Town Clerk ~ / ~S/ 0 2...-
Permit Issued ~ / O? sh ;. Date
, ..
Permit No.
J9V
.
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
BU GAS DESIGN PATCH TtiL:51b 75H513b
KEYSPAN/6AJ'
REQUEST FOR STREET OPENING PERMIT
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PERMIT
NO.
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REASON FOR
oPENING
W,OJPA
NO.
REQUESTED
BY
. APPROVED
SKETCH
o STATE
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