HomeMy WebLinkAbout10885 Peconic Bay Blvd
Date: 05/01/02
Transaction(s):
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 16043
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
Receipt#:
Total Paid:
\
16043
Subtotal
$45.00
$45.00
[nlarnaIID: 53813
Permit No.
/71
,
}71
.
ijtlill'jS
r~~
~~
FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peeonie, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR IDGHW AY EXCAVATION AND REPAIR
Ref.#T100158850
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 ortbe Code of the Town orSouthold, 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 Tvoe
I) KEYSPAN ENERGY -GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE.NY 11801
Name of Applicant Address
2) Russell Williamsou - 10885 Peeonie Bav Blvd. - Mattituck
Name of Owner of Premises
IW.O.#TI 001 588501
Address
3) Ooen & restore Peconic Bav Blvd. - bell hole on the nls I!rass area. aoorox.. 180' wlo Bav Ave. to reactivate a
I!as service to a rebuilt house.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 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.
Other Trade's License No. ~
9At'''~1,; ~.~.
. Sig tnre 0 J\ppli t
04-24-02
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.
5)
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) Starting Date:
Completion Date:
8) Work Schedule:
Phase Comoletio" Date
Excavation..................................... ....................................
Facility Installation...............................................................
Backfill & Compaction.........................................................
Pavement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
n-39
Page 1 of3
Tl00158850
12) Insurance Cover..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 $50,000 property damage.
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Cbeck
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic Application Fee.............. ... $25.00
AI. ~/Servjce Connections excavations@ $20.00 = $ 20.00
No.
A2. _/Additional Excavations same service@$1O.00=$
No.
B. Excavations 18" in depth or less:
0-100 l.f. ~ $10.00
l.f. @ $O.IO~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. = $30.00
_l.f.@$0.30=$
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
l.f. @$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
pennit.
. . .
TOTAL COST $45.00
Authorization is hereby granted to the Town Clerk of the Town of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance v.rith lhis application.
Received by the Town Clerk
~- ao. (I).
0-';} 9-o;;z
Date
Permit Issued
0- / - 0 .l-
Date
Permit No.
/77
Note: Pennit expires one (I) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Pennit must be available for inspection.
D-39
Page 2 of3
AP~-24'22(WED) 0845
SL GAS DESIGN PATC~
TSL'S:S i58S:36
?, C~ 2
F~"'.4
PERMIT
NO.
LOCATION PULJN/~ & l3&b-
REASON FOR . .- J
OPENING IN mli?il/~tIt -/ D
W.OJPA
NO.
REQUESTED
BY
KEYSPAN/6A.f
REQUEST FOR STREET OPI;NING PERMIT
O SUFFOLK I.il
COUNTY ~
D
D STATE
t/l.ll,t~ M
IJ.A-I! 17//It1l: ,4
FOREMAN
S. 3 .loc ~
I ~ Ii __ DEPARTMENT
v.liI ..J&-H~/L GAS CONSTR. I.. ,~.)
-.s"/~
APPROVED
''",SKETCH
tStA'D rr /f)/-'t) r 3
N
,- ,~
I
I
I
I
11;-\
I~
1$
.17
I~.
I;
I
I
I
HJi tit ItJf3B.5
etA.s ZZIo8fJ
( ld;ui lr)
~
-<..
G ~ ,
ti't of
"'"
!ilOrJlC. 'i:: JAY . · t?tl/fJ
(" ~- 1.'-7
'S'StL
....
1-4.
I f{) ':
4~