HomeMy WebLinkAbout310 Ackerly Pond Ln
Date: 06/19/02
Transaction(s):
;1'
'[,:m .-j;
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16214
Total Paid:
-:d 1?7
Name: Key, Span Energy - Gas Cont Oept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NOAC
16214
Subtotal
$45.00
$45.00
Internal 10: 57072
permitNo._} 8 7
FileNo. --1
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peeonie, N ew York II 958
(631) 765-3140
f~'
~
APPLICATIONIPERMIT FOR HIGHWAY EXCA VA TION AND REPAIR
Ref.#TI00170147
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
an EUBvation Permit pursuant to Chapter 83 oflhe Code orlhe 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 inspedors to make necessary inspections of the
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVlLLE. NY 11801
Name of Applicant Address
2) 310 Ackerlv Pond La. Southold
>
.'
3) Ooen & restore a bellhole in the s/s oaved area at the intersection of Lower Rd.. South old
Work Description and Location (Street Number, Hamlet, Cross Street)
.
(a) Is construction located witbin 75 feet of tidal wetlands? *Yes No
*Ifyes, otber Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trad 's License No.
re of A: plica
05-27-02
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 other necessary permits and licenses for this project.
c) Work covered by this application may not commence before issuance of a Highway Excavation Permit
hy the Towu Clerk.
6) Tax Map: Sectiou
. Block
. Lot
7) Startiog Date:
Completion Date:
8) Work Schedule:
Phase Comoletion Date
Excavation....................................................................... ..
Facility Installation............................... ........................ ........
Backfill & Compaction.........................................................
Pavement Replacement................................................. ........
9) Uoder which authority is the applicatioo made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
Tl00170147
12) Insurance Cover..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 annlications and nermits: Basic Application Fee................. $25.00
AI. ~/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.f. ~ $10.00
1.f.@ $0.10 ~ $
Additional
,
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. ~ $
_1.f.@$0.30~$
Additional
D. Excavations 5' in depth and over:
0-100 1.f. ~ $50.00
1.f. @$0.50~$
Additional
E.
Utility Repair Excavations@ $10.00 ~ $
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:
KEYSPAN ENERGY DELIVERY in accordance with this application.
~
Peter W. Harris
r;.. - 1<(-0,)..
Date
Received by the Town Clerk ~ - / q - 0 oLJ
Date
Permit Issued b - It? - 0 J- Permit No.
/87
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.
D-39
Page 2 of3
FC06111.4
PERMIT,
NO.
LOCATION
REASON FOR
OPENING .
W.OJPA
NO.
REQUESTED
BY
. APPROVED
. SKETCH
~oo 'd
KEYSPAN/cfA.f
REQUEST FOR 'STREET OPENING PERMIT
o STATE
D SUFFOLK fX1
COUNTY ~
~ Jj . DEPARTMENT
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