HomeMy WebLinkAbout53345 Route 25
Date: 06/25/02
Transoction(s):
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 16302
*
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
(92/
Receipt#:
Total Paid:
16302
Subtotal
$125.00
$125.00
Intem.IID: 57611
Permit No.
/Cj)
I
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconlc Lane
Peconlc, New York 11958
(631) 765-3140
./
FileNo.
APPLICATIONIPERMIT FOR IDGHW AY EXCAVATION AND REPAIR
Ref.#T100176533
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Soutbold for the issuance of
an Excavation Permit pursuant to Chapter 83 oftbe Code or the Town of Southold, 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 urtbe
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - H1CKSVILLE. NY 11801
Name of Applicant Address
2) 53345 Rt. 25. Southold
Name of Owner of Premises
Address
3) Traveler's St. - 5 bellboles sfs oaved area to directional drill a I!as main under the road shoulder wlo
Beckwith Rd.
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.
ture of pplic
06-18-02
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 which authority is the application made:
10) Estimated Cost of Proposed Work: S
11) Remarks:
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TlOOl76533
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 oennits: Basic Aoolication Fee ............. .... $25.00
AI. _5 ~Service Connections excavations @ $20.00 ~ $ 100.00
No.
A2. _/Additional Excavations same service@$IO.OO=$
No.
B. Excavations 18" 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
_1.[@$0.30~$
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 $125.00
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.
Peter W. Harris
Received by the Town Clerk {g -,;; S - 0 c:V
Date
(;- c')r(-dJ...
Date
Permit Issued f.r, - 0/5 -0 ~ )
Permit No.
/9(2
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.
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