HomeMy WebLinkAbout105 Cindy Ln
Date 06/25/02
Transaction(s):
Town Of Southold
P.O Box 1179
Southold. NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 16303
*11 /
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Namr.:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
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Receipt#:
Total Paid:
16303
Subtotal
$45.00
$45.00
InternallD: 57612
Permit No.
/93
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICA nONIPERMIT FOR HIGHWAY EXCA V AnON AND REPAIR
"'jJot:JI7'1978
Ret 881174978
APPLICA nON IS HEREBY made to the Superintendent of Higbways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 orlbe Code ofthe Town of Southold, Suffolk County, New York, and other
applicable laws, ordinances or regulations for tbe excavation berein described. The applicant agrees to comply with all
applicable laws, ordinances, codes and regulations, and to permit authorized inspectors to make necessary inspections orlbe
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - mCKSVILLE. NY 11801
Name of Applicant Address
2) 105 Cindv Lane. Mattituck
Name of Owner of Premises
Address
3) ODen & restore a bell hole on the w/s oaved area Boorox. 150' sle of Deer Dr.. Mattituck
Work Description and Location (Street Number, Hamlet, Cross Street)
<a) Is construction located within 75 feet oftidal wetlands? *Vcs
*If yes, other Town permits may be required.
No X
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
Signatnre of Applicant
06-12 -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 Comoletion Date
Excavation............................ .............................................
Facility Installation.................................................. .............
Backfill & Compaction.........................................................
Pavement Replacement. ...... .... ..... ............ .... ..... ......... ....... ....
9) Under wbich anthority is tbe application made:
10) Estimated Cost of Proposed Work: S
11) Remarks:
D-39
Page lof 3
Tl001174978
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 Annlication Fee................. $25.00
AI. -1-IService Connections excavations @ $20.00 = $ 20.00
No.
A2. -"Additional Excavations same service@ $10.00 ~ $
No.
B. Excavations IS" in depth or less:
0-100 1.( ~ $10.00
1.( @ $O.IO~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.( = $30.00
_I.f.@$0.30~$
Additional
D. Excavations 5' in depth and over:
0- I 00 1.( ~ $50.00
1.( @ $0.50 ~ $
Additional
Utility Repair Excavations @ $IO.OO~ $
E.
No.
Repairs sarne 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.
Peter W. Harris
Received by the Town Clerk & - r2 -5"'0 eLJ
(e 'J)rf- d ,;).
Date
Permit No.
) 9-3
Permit Issued ~ -,;(0'- ()r:J...;
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
KEYSPAN}6AJ"
REQUEST FOR STREET OPENING PERMIT
FC-8111.'
o STATE
D SUFFOLK
COUNTY
D
PERM
NO.
LOCATION
t.'
REASON FOR .,..
OPENING ~~
W.OJPA
NO.
REQUESTED
BY
I ~ ~I DEPARTMENT
VI/I -Julu72.- GASCONSTR. L.~,)
, APPROVED
SKETCH
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