HomeMy WebLinkAbout530 Hobart Rd
Date: 06/13/02
Transaction(s):
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16212
Total Paid:
J
~ f~
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
16212
Subtotal
$90.00
$90.00
Internal 10: 56743
Permit No.-I--f?----1--
FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLlCATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100169752
APPLICATION IS HEREBY made to the Superintendent of Highways orthe Town of Southold for the issuante of
an Excavation Permit pursuant to Chapter 83 urtbe Code urtbe Town of Southold, Suffolk County, New York, and other
applicable laws, ordinances or regulations for the excavation herein described. The .pplit:ant agrees to comply with all
applicable laws, ordinances, codes and regulations, and to permit authorized inspectors to make necessary inspections ufthe
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVlLLE. NY 11801
Name of Applicant Address
2) 530 Hobart Rd.. Southold
>
3) ODen & restore a 150' trench in the els oaved roadway at the intersection of Kurn Rd.. Southold.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is tonstruction located within 7S 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.
Jr
ure f pplic t
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
by the Town Clerk.
6) Tax Map: Section
,Block
,Lot
7) Startiug Date:
Completion Date:
8) Work Schedule:
Phase Comnletion Date
Excavation............................ ....... ......................................
Facility Installation.... ........................................... ......... ... ....
Batkflll & Compaction........................................ ... ..............
Pavement Replatement....... .... ..............................................
9) Under which authority is the applicatiou made:
10) Estimated Cost of Proposed Work: $
II) Remarks:
D.39
Page 1 of3
Tl00169752
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 $50,000 property damage.
13) Securitv:
a)
provided in the total amount
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
2 years or
3 years
14) Fees for aoolications and oermits: Basic ADDUcatioD Fee................. $25.00
AI. --1-/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.[ ~ $10.00
1.[ @$O.IO~$
Additional
C. Excavations 18" in depth to 5' in depth: ISO'
0-100 l.f. ~ $30.00
50 l.f. @ $0.30 ~ $ 15.00
Additional
D. Excavations 5' in depth and over:
0-100 l.f. ~ $50.00
1.[ @ $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 $90.00
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
Received by the Town Clerk b /;.3 /t;;2J
/ / 'Date
Permit Issued ~ {,1 tJ ~
I I
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.
{p- J<I- O~
Date
Permit No.
I Pc..;
D-39
Page 2 of3
MAY, '2f.021FRI) 11:43
au GAS DESIGN PATCH TEL:516 7585136
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