HomeMy WebLinkAbout140 Mechanic St
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 04/22/03
Receipt#: 12981345
1 Permits
Check#: 1298/1345
Total Paid:
Subtotal
$45.00
$45.00
Transaction(s):
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Name:
Key, Span Energy. Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
InternallD: 73662
Permit No. . b ~
File No. -if )
TOWN OF SOUTH OLD
HIGHWAY DEPARTMENT
Peeonie Lane
Peeonie, New York 11958
(631) 765-3140
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APPLICATlON/PERMlT FOR HIGHWAY EXCA V ATlON AND REPAIR
Ref.#T1 00269430
APPLICATION IS HEREBY made to the Superintendent of Highways ortbe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 ortbe Code orthe 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 inspectors to make necessary inspections orthe
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Addrc~s
2) 140 Mechanic Street. Sonthold
Name of Owner of Premises
Address
3) Mechanic Street - hellhole in front of house #140. 125' wlo Younl!s Avenue in order to reoair a I!as leak
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction 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.
Signature 0 ~pp
04-09-03
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 which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
Tl00269430
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: $300,0001$500,000 Bodily Injury, and $50,000 property damage.
13) Securilv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oennits: Basic Aoolication Fee.............. ... $25.00
A!. ~/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 1.[ ~ $10.00
1.[ @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.[ ~ $30.00 ~
_l.f.@$0.30=
Additional
D. Excavations 5' in depth and over:
0-100 1.[ ~ $50.00
1.[ @ $0.50 ~ $
Additional
E.
Utility Repair Excavations @ $1 0.00 ~ $
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:
KEYSP AN ENERGY DELIVERY in accordance with this apph::r.tion.
SUPE. R~. . ENT OF. HIGHW J\. YS
TO~FSO THO~D'N~RK
vI,:" 1 {i) .~
Peter . Harris
Received by the Town Clerk ...; /cJ02/t> 3 ~()mfJ/~{'-
Permit Issued '-1/22-/0 b Date Permit No. d53
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.
0.39
Page 2 of3
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