HomeMy WebLinkAbout2340 Fairway Dr
Date: 04/21/03
Transaction(s):
Name:
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 1254
Total Paid:
/D
~~~
Key, Span Energy - Gas Cant Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
1254
Subtotal
$45.00
$45.00
Internal 10: 73515
Permit No.
a5D
rJ.,v
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
f~'
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FileNo.
APPLICATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#Tl 0026551 0
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 oftbe 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 Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - H1CKSVILLE. NY 11801
Name of Applicant Address
2) 2340 Fairwav Drive. Cutchol!ue
Name of Owner of Premises
Address
3) Fairwav Drive - bellhole e/s 2rass area annrox. 300' n/o Greenwav to install a 2as service at house #2340
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? .Yes
"'If yes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Tr
e of Ap
04-04-03
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 Towo Clerk.
6) Tax Map: Section
. Block
. Lot
7) Starting Dote:
Completion Date:
8) Work Schedule:
Phase Comnletion Date
Excavation................... ......................................................
Facility Installation...................................... .........................
Backfill & Compaction.........................................................
Pavement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
1 ]) Remarks:
0-39
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 $50,000 property damage.
Tl00265510
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic Application Fee................. $25.00
AI. -L}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 l.f. ~ $10.00
1.( @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.( ~ $30.00 ~
_1.f. @$0.30=
Additional
D. Excavations 5' in depth and over:
0-100 1.( ~ $50.00
l.f.@ $0.50 ~ $
Additional
E.
No.
_ Utility Repair Excavations @ $1 0.00 ~ $
Additional
Repairs same service @$S.OO = $
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 Southald to issue a Highway Excavation Permit to:
KEYSP AN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk_
,-1//7/1J3
l.J1/E-11J .,
Permit Issued
Date
Permit No.
q~?)
Note: Permit expires one (1) year trom 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
MAR,c31'03(MONj 14:37
FC-lIl1 L4
PERMIT
,NO.
LOCATION
REASON FOR
OPENING
W,OJPA
NO.
REQUeSTED'
" BY
, APPROVED
SKETCH
, ,
, '
BU GAS DESIGN PATCH TEL:516 7585136
KEYSPAN~A.r ,
REQUEST FOR STREET OPENING PERMIT
' ,
O "0' NASSAU '0 SUFFOLK, Ic7I (") '.-J,; .JJ
: STATE 'COUIllY COUNTY I.Cj ~t1:!..(J~
' MISJO~ DATE, '
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FOREMAN DATE 'OF A
OPENING 'r, I"tl ~:3
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