HomeMy WebLinkAbout3400 Soundview Ave Ext
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ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #181
Key, Span Energy- Gas Cant Dept
175 E Old County Rd
Hicksville, NY 11801
Received $ 45.00
1 - Permits on OS/20/2002.
Thank you.
Permit No.
If 1
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FileNo.
11ft
TOWN OF SOUTHOLD
ffiGHWAYDEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATlONIPERMIT FOR ffiGHW AY EXCAVATION AND REPAIR
Ref.#TlOOI64509
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 oftbe Town of Sonthold, 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 urthe
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 3400 Soundview Ave. Ext.. Southold
Name of Owner of Premises
Address
3) ODeD and restore a bellhole in the oaved area 20' e!o the intersection with Lil!hthouse Rd.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet oftidal wetlands? *Yes No
*Ifyes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
.r~
re of pplic
05/10/02
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 bef-ore issuance of a Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section
.Bloek
. Lot
7) Startiug 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
Tl00164509
12) Insurance Coveraee: (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 aoolications and oermits: Basic Aoolication Fee................. $25,00
A I. ~/Service Connections excavations @ $20.00 ~ $ 20.00
No.
A2. ~/ Additional Excavations same service @ $1 0.00 ~ $
No.
B. Excavations 18" in depth or less:
0-100 !.f. ~ $10.00
!.f.@$0.1O~$
Additional
c. Excavations 18" in depth to 5' in depth:
!.f. @ $0.30 ~ $
Additional
D. Excavations 5' in depth and over:
0- I 00 !.f. ~ $50.00
!.f. @$0.50~$
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 $45.00
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
oS /11 /0 Z.
,<S- IS-:-Od-..
Date
Permit Issued 61~d 2-
Date
Permit No.
I &'1
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
CODY Distribution:
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MAY,,-09"02(THU) 08:20
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PERMIT.
NO,
LOCATION
REASON FOR
OPENING
W,OJPA
NO.
REQUESTED
BY
, APPROVED
SKETCH
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BU GAS DESIGN PATCH TEL:5!6 7585136
KEYSPAN/~A..s'
REQUEST FOR STREET OPENING PERMIT
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