HomeMy WebLinkAbout445 White Eagle Dr
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 06/19/02
Receipt#: 16073215
1 Permits
Check#: 16073/16215
Total Paid:
Subtotal
$45.00
$45.00
Transaction(s):
::::If / g~
. .~".
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
IntemallD: 57059
~
~ennit No.
TOWN OF SOUTHOLD
IDGHWAYDEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
FileNo.
APPLlCATION/PERMIT FOR IDGHWAY EXCAVATION AND REPAIR
Ref.#T100160302
APPLICATION IS HEREBY made to the Superintendent of Highways of tbe Town of Soutbold for tbe issuance of
an Excavation Permit pursuant to Chapter 83 of tbe Code oftbe Town of Soutbold, 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. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 445 White Ea2le Drive. Laurel
Name of Owner of Premises
Address
3) ODeD & restore a bell hole OD the wls iD the 2ra.. area at the intersection of Ea2le Nest Ct.. Laurel
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.
re of Ap
04-30-02
Date
5) a) Attach plot piau showiug 10catioD of proposed excavatioD aod 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: Section
. Block
. Lot
7) Starting Date:
Completion Date:
8) Work Schedule:
Phase Comoletion Date
Excavation.. ........................ ......... ................................ .-....
Facility Installation........ .............................. ..,............ ..........
Backfill & Compaction....................................;....................
Pavement Replacement..... ...... ......... ... ...... ........... .... .............
9) UDder which authority is the appllcatiou made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
e
1~
.
.
Tl00160302
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 acclications and cennits: Basic Aoolicatioo Fee ................. $25.00
AI. ~Service Connections excavations @ $20.00 ~ $ 20.00
No.
AZ. ~Additional Excavations same service @$1O.00 = $
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
I.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
l.f. @ $0.50 = $
Additional
Utility Repair Excavations @ $10.00 = $
E.
No.
Repairs same service @ $5.00 = $
Additional
TOT
F. Notice to public utilities proof must be provided and attached to this application prior to issu
pennit.
* * *
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.
Received by the Town Clerk '" - / fl- 0 CL/
1 Date
Permit Issued rc - /9 - 0 ~ Pennit No.
SUPERINTENDENT OF HIGHWAYS
TOWN~~H(Un :~H,rRK.
.~&~
Peter W. Harris
~/3/t?...7
Dalt
jf's-
\
Note: Permit 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
CODY Distribution:
Highway Department
'AP~. -2"g'.:).(\6~) 1 :'48
Fe.Bl11.'
PERMIT
NO.
l.OCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
3J GAS JESIGN PATC~ TE~516 7585:36
KEYSPAN/6AS
REQUEST FOR STREET OPENING PERMIT
o STATE
P QC4
o
O SUFFOLK r:7l
COUNTY LtJ
~ss #-lA AY 71fl (1J~,(S~h'o;./ "f
~ JJ __ DEPARTMENT
...J(,Hp..IZ- GAS CONSTR. L ,%.)
I'.ttJ ;L
L.l;,.I"~
u)(..1,.t
~
('II
~
-R..
~
l.I\
--j 7 h'
/' .
~
r:
~
-J'"'/~
~l-tb d: 0<15-5;- cJ.-
N
~
~
~
I'"
~
~
1"'\
N
~:
"'"
to,
-\
....0..
><.
~
bl:tU.
IJ eS7
t.-(:
t;/
\'
I
I