HomeMy WebLinkAbout1890 Oaklawn Ave
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: OS/20/02
Receipt#:
16109
1 Permits
Check#: 16109
Total Paid:
Subtotal
$45.00
$45.00
Transaction(s):
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
Internal 10: 54963
.
Permit No.
/79
TOWN OF SOUTHOLD
IDGHWAYDEPARTMENT
Peconic Lane
Peconic, N ew York 11958
(631) 765-3140
FileNo.
APPLICATIONIPERMIT FOR IDGHW AY EXCAVATION AND REPAIR
Ref.#T100165646
APPLICATION IS HEREBY made to the Superintendent of Wgbways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of Southold, 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 tbe
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - mCKSVlLLE. NY 11801
Name of Applicant Address
2)
1890 Oaklawn Avenne. Sontbold
Name of Owner of Premises Address
3) Oaklawn Avenue - bellhole e/s Ilfass area aDorox. 275' slo Jernick Lane. Southold
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet oCtidal wetlands? *Yes No
*If yes, other Town permits may be required.
4) Bunder's License No.
Plumber's License No.
Electrician's License No.
of App Icant
14-02
Date
5) a) Attacb plot plan sbowlng location of proposed excavation and relationsbip 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 tbe Town Clerk.
6) Tax Map: Section
. Block
. Lot
7) Startiog Date:
Completion Date:
8) Work Scbednle:
Phase Comnletion Date
Excavation.................... ..... ...... ......................... .................
Facility Installation........ ......... ........................... ...... .............
Backfill & Compaction.........................................................
Pavement Replacement................................... ......................
9) Under wbicb autbority is tbe applicatioo made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
e
~
Tl00165646
12) Insurance Covera.e: (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 Application Fee ........... ...... $25.00
AI. --1-fService Connections excavations @ $20.00 = $ 20.00
No.
A2. ~Additional Excavations same service@ $10.00 ~ $
No.
B. Excavations IS" in depth or less:
0-100 1.[ ~ $10.00
1.[ @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 Lt. = $30.00
_1.[ @ $0.30 ~
Additional
D. Excavations S' in depth and over:
0-100 1.[ = $50.00
1.[ @ $0.50 = $
Additional
E.
Utility Repair Excavations@ $10.00 ~ $
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 Southald to issue a Highway Excavation Pennit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Peter W. Harris
Received by the Town Clerk 5- 17. tJ .;L.-
I Date
Permit Issued ,:,101. 0 I 0 )- Permit No.
,0- /lJ-CJ;)..
Date
/79
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Pencil must be available for inspection.
D-39
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