HomeMy WebLinkAbout150 Hillcrest Dr
Date: OS/20/02
Transaction(s):
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16129
Total Paid:
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
16129
Subtotal
$432.00
$432.00
Internal 10: 54961
Permit No.
/11
/1r
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
FileNo.
APPLICATIONIPERMlT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100164542
APPLICATION IS HEREBY made to the Superintendent of Highways urthe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code oftbe Town oCSouthold, 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 TVDe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2)
1 SO Hillcrest Drive. Orient
Name of Owner of Premises Address
3) Heath Drive. oDeD & restore a bell hole on the w/s and 1060' trench nlo Main Rd.. missile shot across
Hillcrest Dr. with a test hole over the UG electric in the oaved area and 230' trench west in the nls llrass
area of Hillcrest Dr.. Orient.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*lfyes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
re of A: pli
05-14-02
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 before issuance of a Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section
,Block
. Lot
7) Startiog Date:
Completion Date:
8) Work Schedule:
Phase ComDletion 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
Pagelof3
Tl00164542
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 $50,000 property damage.
13) Security:
a)
b)
Surety Bond
of$
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
AI. ~Service Connections excavations @ $20.00 ~ $ 20.00
No.
A2. ~ Additional Excavations same service @ $ I 0.00 ~ $
No.
B. Excavations 18" in depth or less:
0-100 I.f. ~ $10.00
I.f.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth: 2 trenches -1060' aod 230' ~ 1,290'
0-100 I.f. - $30.00
1190 J.f. @$0.30- $357.00
Additional
D. Excavations 5' in depth and over:
0-100 I.f. - $50.00
I.f. @ $0.50 - $
Additional
E.
Utility Repair Excavations@$IO.OO-$
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 $432.00
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.
Received by the Town Clerk 5/1 7 / /)OJ-
/ / Date
Permit Issued .5 d-o / 0 .;u Permit No.
.
s:- 1'7-62-
Date
/7 cP
Note: Permit expires one (I) 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
MAY, -lr ~'(MON) 08:32
BU GAS DESIGN PATCH TEL:516 7585136
KEYSPAN/~S
REQUEST FOR STREET OPENING PERMIT.
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COU>lTY
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