HomeMy WebLinkAbout255 Calves Neck Rd
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Date: 06/19/02
Transactlon(s}:
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Name:
1 Permits
Check#: 16211
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Recelpt#:
Total Paid:
~10
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
16211
Subtotal
$195.00
$195.00
Internal 10: 57074
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Permit No.
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peeonie, New York 11958
(631) 765-3140
FileNo.
APPLlCA TION/PERMIT FOR HIGHWAY EXCA V ATlON AND REPAIR
Ref.#TlOOI69742
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South old for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the 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 of the
job site.
Print or TVDe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - H1CKSVILLE. NY 11801
Name of Applicant Address
2) 255 Calves Neck Rd.. Southold
>
3) Ouen & restore a 500' trencb in tbe n1s 2rass area from intersection of Hamer Rd.. South old.
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.
fAp
27-02
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 otber necessary permits and licenses for tbis 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 Scbedule:
Phase Comoletion Date
Excavation.. .......................................................................
Facility Installation...............................................................
Backfill & Compaction.........................................................
Pavement Replacement. ............... ... ....... ..... ............ .... ... .......
9) Under which authority is tbe application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
Tl00169742
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: $300,000/$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 ADDlication Fee ................. $25.00
AI. ~/Service Connections excavations@ $20.00 = $ 20.00
No.
A2. _I Additiooa1 Excavatioos same service @ $ I 0.00 ~ $
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: 500'
0-100 I.f. ~ $30.00
400 I.f. @ $0.30 ~ $ 120.00
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
I.f. @ $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 $195.00
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
(;,- (c(-o)..
Date
Received by the Town Clerk ~ - / tf - Ov
Date
Permit Issued t, - / t; - O~ Permit No.
/ ~f
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 0(3
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NO.
IEQUEBTED
BY
APPROVED
MAY.-25'02(SAT) 15'14
BU GAS DESIGN PATCH
TEL 516 7585136
P. 015
KEYSPAN/6'"AS'
REQUEST FOR STREET OPENING PERMIT.
12
DEPARTME "
GAS CONBTR. llollh: >141?""""C.
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