HomeMy WebLinkAbout4785 Stillwater Ave
.
Date: 06/20/02
Transaction(s):
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 16294
*
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
Receipt#:
Total Paid:
16294
Subtotal
$255.90
$255.90
InternallD: 57201
Permit No.
/90
I
TOWN OF SOUTHOLD
ffiGHWAYDEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
FileNo.
APPLICATIONIPERMIT FOR ffiGHW AY EXCAVATION AND REPAIR
Ref.#T100170636
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 orlbe Code ortbe Town of Southold, Suffolk County, New Yor~ 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 uftbe
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - H1CKSVILLE. NY 11801
Name of Applicant Address
2) 4785 Stillwater Ave.. Cutchoeue
Name of Owner of Premises
Address
3) Stillwater Ave. - bellhole and a 703' trench in the grass area approx. 300' nJo Pequash Ave., Cutchogue
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.
Other T
5)
nre of plica
06-17-02
Date
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: Sectiou
,Block
,Lot
7) Startiug 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: $
II) Remarks:
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Tl00170636
12) Insurance Covera.e: (Attach Copy)
a) Insurance Company:
b) Policy#
c) State whether pnlicy 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 aonlications and nermits: Basic ADDlication Fee ................. $25.00
AI. ~Service Connections excavations@$20.00=$ 20.00
No.
A2. _I Additional Excavations same service @ $1 0.00 ~ $
No.
B. Excavations 18" in depth or less:
0-100 I.f. ~ $10.00
1.[ @$O.IO~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.[ ~ $30.00 ~ $30.00
603 I.f. @ $0.30 ~ $ 180.90
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
1.[ @ $0.50~ $
Additional
Utility Repair Excavations @ $10.00 ~ $
E.
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 $255.90
Authorization is hereby granted to the Town Clerk afthe Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SU~e~T OF HIGHWAYS
TO~~~~C
Peter W. Harris
Received by the Town Clerk
~ -/~-Oz..
{G'~l q -o~
Date
Permit Issued
(.,-.;20.0)-
Permit No.
/90
Date
Note: Permit expires one (I) 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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