HomeMy WebLinkAbout120 Cottage Pl
Date: 04/21/03
Transaction(s):
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 1324
Total Paid:
~)~l
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
1324
Subtotal
$45.00
$45.00
Internal 10; 73516
Permit No.
:25/
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peeonie, New York II958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100270313
APPLICATION IS HEREBY made to the Superintendent of Highways orthe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 ofthe Code or 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 Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSY1LLE. NY 11801
Name of Applicant Address
2) 120 Cottaee Place. Southold
Name of Owner of Premises
Address
3) Cotta!!e Place - bellhole in front of house #120.135' slo Main Road in order to reoair a e:as leak
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
'/tUyes, other Town permits may be required.
No~X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Tra
ignature 0 Appr
04-14-03
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 Towu Clerk.
6) Tax Map: Sectiou
, Block
,Lot
7) Starting Date:
Completion Date:
8) Work Schedule:
Phase ComnIetion Date
Excavation.... _.. _ _............................... _.. _.. _..........................
Facility Installation. _........ _... _..._ _.................... _.. _.. _............ ....
Backfill & Compaction_.............................. _ _.. _.....................
Pavement Replacement.......... _..... _....................... _._..............
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
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 $50,000 property damage.
Tl00270313
13) Securitv:
a)
b)
Surety Bond_
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aDDl1catlOns and perm.ts Basic Application Fee................. $25.00
AI. ~Service Connections excavations @ $20.00 ~ $ 20.00
No.
Al. ~/Additional Excavations same service@$10.00=$
No.
B. Excavations 18" in depth or less:
0-100 1.1. ~ $10.00
1.1.@ $0.10 ~ $_
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. ~ $30.00 ~
_1.f.@$O.30=
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
1.1. @ $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 $45.00
Authorization is hereby granted to the To'Ml Clerk of the To'Ml of Southold to issue a Highway Excavation Pennit to:
KEYSP AN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk. 6(/';"-/1),3
-'")j; (;..1.03 Date
Permit Issued Q' # _ _
r .
Permit No.
<10f
Note: Pennit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Pennit must be available for inspection.
D-39
Page 2 of3
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iKE'YSPAN ENERGY DELIVERY I
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ADDRESS
120 COTTAGE
TOWN
SOUTHOLD
>>1ST FR CROSS ST
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GRID
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~ late Plotted: 4/9/2003
cale: lin= 25ft
:ion on this document has been supplied
s sole use and is not to be relied on by 01
:ed may not accurately reflect the actual
Center Grid: 108-17-1148
Lavers Printed: Detail Gas (50')