HomeMy WebLinkAbout355 King St
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #180
Key, Span Energy- Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Received $ 45.00
1 - Permits on OS/20/2002.
Thank you.
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconie, New York 11958
(631) 765-3140
Permit No.
FileNo.
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#TlOOI65446
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South old for the Issuance of
an Excavation Permit pursuant to Chapter 83 oflbe Code oftheTowD of Soutbold, SurrolkCounty, 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
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -17S E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 3SS Kine Street. Orient
Name of Owner of Premises
Address
3) ODeD and restore a bellhole on the nls 2rass area aoorox. 25' e/o Willow Terrace Lane.. Orient to tube and
relocate an existine- e-as service.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
re of Appr ant
05/10/02
Date
S) 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 Scbednle:
Phase Comoletion Date
Excavation.......... ............................................................ ...
Facility Installation.............. .............................. .............. .....
Backfill & Compaction.........................................................
Pavement Replacement.........................................................
9) Under which anthority is the application made:
10) Estimated Cost of Proposed Work: $
ll) Remarks:
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T1 00 165446
12) Insurance Coveraoe: (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 $50,000 property damage.
13) Security:
a)
provided in the total amount
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
2 years or
3 years
14) Fees for aoolications and oermits: Basic 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
l.f.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
l.f. @ $0.30 ~ $
Additional
D. Excavations 5' in depth and over:
0-100 l.f. ~ $50.00
l.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 South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Peter W. Harris
Received by the Town Clerk 6-f; 1/0 2.-
Permit Issued 61~6 2--
s - /.5,--- dd-...
Date
Date
Permit No.
/go
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
KEYSPAN/~AJ"
REQUEST FOR STREET OPENING PERMIT
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