HomeMy WebLinkAbout400 Richmond Rd
Date: 04/21/03
Transaction(s):
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 1281
Total Paid:
J: ~ctq
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
1281
Subtotal
$45.00
$45.00
InternallD: 73514
Permit No.
~41
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FileNo.
TOWN OF SOUTH OLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic. New York 11958
(631) 765-3140
APPLlCA TlONIPERMIT FOR HIGHWAY EXCA V A nON AND REPAIR
Ref.#T100267540
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 of the Code or the Town of South old, Suffolk County, New York, aod 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) 400 Richmond Road. Southold
Name of Owner of Premises
Address
3) Richmond Road - bellhole e/s Daved area aoorox. 385' s/o North Road to install a eas service to #400
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S 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.
's License No.
Signat of App
04-07-03
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 Town 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) 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 $50,000 property damage.
Tl00267540
13) Securitv:
a)
b)
Surety Bond
01$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aDohcatlOns and oermlts Basic AODlication 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 l.f. ~ $10.00
l.f. @$O.IO~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.f. ~ $30.00 ~
_1.[. @ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 l.1. ~ $50.00
l.f. @$0.50~$
Additional
E.
No.
Utility Repair Excavations@ $10.00 ~ $
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\Vll Clerk of the To\Vll of Southold to issue a Highway Excavation Permit to:
KEYSP AN ENERGY DELIVERY in accordance with this application.
Permit Issued
'-I ~ I~-o 7
Date
'1/;,/03
.
ENT OF HIG~W A S
HO"W, NEW >tJ RK
.......' :~~
is
Received by the Town Clerk_~
Permit No.
-1'17
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.
D-39
Page 2 of3
APR,-01'U3ITUE) 09:12
f'c.B111 A
PERMIT,
NO.
LOCATION
REASON FOR
OPENING
W,OJPA
NO.
REQUESTED'
, BY
, APPROVED
SKETCH
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BU GAS DESIGN PATCH TEL:5!6 i585136
, KEYSPANltfA.i "
REQUEST FOR STREET OPENING PERMIT
p, 002
o :STATE
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