HomeMy WebLinkAboutInlet Pond Rd
Date: 06/20/02
Transaction(s):
Name:
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 16293
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Receipt#:
Total Paid:
16293
Subtotal
$117.00
$117.00
Internal 10: 57203
Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
FileNo.
APPLICATIONIPERMIT FOR mGHW A Y EXCAVATION AND REPAIR
Ref.#T100176023
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuam:e of
an Excavation Permit pursuant to Chapter 83 oftbe Code ofthe Town of Southold, Suffolk County, New York, and otber
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 of the
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) Inlet Pond Rd.. Greenoort
Name of Owner of Premises
Address
3) Inlet Pond Rd. & Green Hill La. - bellbole in sfs paved area of Inlet Pood Rd. and a 240' trencb easterly in
the s/s grass area, missile under the road to the els grass area of Green Hill La. & 70' trench in e/s grass
Work Description and Location (Street Number, Hamlet, Cross Street)
<a) Is construction located within 75 feet oftidal wetlands? *Yes No
*Ifyes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
re of A
06-17-02
Date
5) a) Attacb plot plan showing location of proposed excavation and relationsbip 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 tbe Town Clerk.
6) Tax Map: Section
,Block
,Lot
7) Starting Date:
Completion Date:
8) Work Scbednle:
Phase Comoletion Date
Excavation....... ............................................. .... .................
Facility Installation.......................................................... .....
Backfill & Compaction.........................................................
Pavement Replacement................................... ........ ..............
9) Under which antbority is tbe application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
r~'
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D-39
Page 1 of3
Tl00176023
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 $50,000 property damage.
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic Annlication Fee................. $25.00
A 1. ~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:
0-100 I.f. = $30.00 ~ 530.00
140 I.f. @ $OJO ~ $ 42.00
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
1.f.@$0.50~$
Additional
E.
Utility Repair Excavations @ $10.00 ~ $
No.
Repairs same service@$5.oo= $
Additional
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
. . .
TOTAL COST $117.00
Authorization is hereby granted to the Town Clerk oftbe Town of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPERINTENDENT OF HIGHWAYS
TOV~~~~
Peter W. Harris
Received by the Town Clerk
b- jtJ-O ^
Cd! - 0 J-
Date
Permit Issued fo - n2 0 -0 0..
Date
/ q I
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.
D-39
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