HomeMy WebLinkAbout1500 Latham LnTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 03/20/03
Transaction(s):
1 Permits
Receipt#:
1194
Subtotal
$45.00
Check#: 1194
Total Paid:
$45.00
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 72040
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100262784
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 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 the
job site.
Print or Type
1) KEYSPAN ENEKGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ lh~' llS01
Name of Applicant Address
2) LathamLane-be~~h~~es/snrassareaandatesth~~einpavedarea~verthee~ectricprimar~appr~x. 100'
e/o Land's End Road. OrienL to install a uss service to house #1500
Name of Owner of Premises Address
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) ls construction located within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
5)
No X
Plumber's License No.
Other Tra~..~
Date
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
7) Starting Date:
8) Work Schedule:
, Block , Lot
Completion Date:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Completion Date
D-39 Page 1 of 3
T100262784
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) Security:
a)
Surety Bond or Certified Check provided in the total amount
nfs
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for annlications and oermits: Basic Application Fee ................. $25.00
Al. I /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.f. = $I 0.00
l.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.f. = $30.00 =
__ 1.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-1001.f. - $50.00
I.f. ~ $0.50 = $
Additional
NO.
Additional
Utility Repair Excavations @ $10.00 = $
Repairs same service ~ $5.00 = $
Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST $45.00
Authorization L hereby granted to ire Toyota Clerk of the Town o£ Southmd to issue a ltighway Excavatior Pert fit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk ,~/t~9O/O
Permit Issued Permit No.
SUPERtN~NDENT OF HIGHWAYS
TOJNN OF ~OUTI~OLD, N¢~V YORK
Peter W. Harris
o76/7
Note: Permit expires one (1) year from Date of Issuance. No work to start w/thout 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
~AR.-1EOS(TUE) 09:04
PERMIT·
LOCATION
RE. A$ON FOR
OPENING
BU GAS DESIGN PATCH TEL:516 7585156
J~J] 'STATE
KEYSPAN/~ .
REQUEST FOR'STREET OPENING PERMIT'
· COUNTY OOUNTY ' [~
MIS gOB ~
No.
SKETCH
DATE 'OF
OPENING
DATE
?0o'" 2
Date: 04/17/06
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
ReceiptS: 1407
Transaction(s):
1 1
Permits
Reference Subtotal
441 $150.00
Check#: 1407
Total Paid: $150.00
Name:
Utilities, Plus Corp
99 Mariner Dr
Southampton, NY 11968
Clerk ID: LINDAC Internal ID: 441
TOWN OF SOUTNOLD
HIGHWAY DEPARTMENT*
Peconlc Lane
Paconlc: I~le~ York 1.1958:
AppLiCAI~ION/PIERM/T FOR HiGHI~AY. EXC. AVAT. ION AND R,E, PA,I.R.
· 11)
APPLICATION IS HEREBY made to.the Superintendent of High,rays of the Town
of ~outhold for the Issuance ef ~1 Excavati~h Permit 'purs~nt to Chapter 83 of the
of To,. of s s. k ·
ordir~nces or r~gulaflona for the e~cava~n harm. u~.w ~-r ,
tO cOmply Wltti all applicable laWS, ordln~ulces, code~ and regulaUo~s, and to permit
authorlz~l Inspectors t~ ~ake] nec~ary in~pecUohs of the job sit&.
Print or Type
' Name ~-f Applicant ' '"' Address
'~ Name ef OySter 7~f Premi~ ^ddre~a
Z) ~'f l ,.f,,~ l t.- ~ / x., ; , ..q~ e~ ,. , , .. ,.,..,,
Work Description and Location [Street Number~ Hamlet, Cross S~-~
iai Is cmmtrucUOn located wlthli~'75 feet of tJdal wetlands['
· If ye~o other' Town permlt~ may be required.
e,) ]Buildmas .LicenSe .No. Piumber~ Li~xtse No .....
Electrlc~ah*s Lic~se No. Other Trade's License No.
- ' Signature of Ap~pllcant
Date.
b) ^~tach all ~ ne~e~rY pe~nit~ and li~-~n$~ fer this 'pro~e~t.
· ¢) · ~k,.c~e~ by this applic~tlo~ ~my not cemmenc~ bef~ i~uance efa
NighWay ExcaYe~o~ P~rrnit ~ the Town
Tax Map.' Section
7) Starting Date~
8} Work Schedule
Phase
cc~:rapleUoh.
Facility Insmllatloh ................................. ..
Pavement Replacement ..............................
Under which authority Is the eppIIc~tlot~ made:04~
Estimated Cost of Proposed Work:
D-39 Page. 1 of 3
d) Coverage required extended to the Town:
Bodily Injury and property damage: ~301L000/$500,000 Bodil~ Injury,
and $5O, OOe-property' damage.
13) SecurltY~:
- a) Surety Bend. . ...o~ CertJfiecl Check provided In'the
total amount of $ · ...-
b) Maintenance Bbnd provided= '2 years or . .3 years.
Fees for applic~Riohs and perm_it~J
Al. IServic~ Connectiof;~s excavations e $20.00 r- $~ . ...
/[2. /Additi~al Excavations eame service e $10.00 -- ~L , --
Excavafiohs 18" in depth.or less:
0-'IN l.f. = ~1g,0o'
I.f.
AddiUo~al
C. Excavatlo~s 18" in depth to S~ in depth;
0-10~ I,f. =
I.f.
Aaditio'r~al'
D. ~ccavaUo~s ~ in depth a~ ow~r:
AddiUo~al
E.
Ho.
Utility Repair ExcavaUohs ~L~4..O. Oa ~- $
Authoriz;itlo~ Is hereby granted to the Town Clerk of the To~nl of S~uthold to
issue a Highway Excnvatlo~ Pernit *to: :. -
in'acCordance with this 'applic;Itlol~.
_~DENT OF HIGHWAYS
UTHOLD~ ,t~ YORK
eter II/. HarJ'i& i"/ /'
Receded by the Town Clerk
Date
Permit 'l~5ued L//~ [ 7~ 0 C- Permit 'No.
Pe~ait expires one (].) year from. Date of Issunnce, - _
No work to start wlttiout a~8 hour notJ;e to tha Suporlntenoqn[ of Highways.
Permit'must be a,vnil~ble for
,C~, y Distributloh:
Highway Department
InSpector
Applicant
Town Clerk
iN SPECTOR".,$, ,RE,CORD
Inspection Date Findings (use ~Xle)
App{Ic~nt Notified
..... (T~ P&rmit 'Clerk)
REMARKS
CODE
Page 3 of 3
OF LIABILITY INSi