HomeMy WebLinkAbout1100 Skunk Ln
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 05/01/02
Receipt#:
16051
1 Permits
Check#: 16051
Total Paid:
Subtotal
$55.00
$55.00
Transaction{s}:
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
Internal 10: 53812
Permit No.
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR mGHW AY EXCAVATION AND REPAIR
Ref.#TIOOI59283
APPLlCA nON IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 orthe Code of the Town of Southold, Suffolk County, New Yor~ 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 insped:ions urthe
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) Mr. Gerald Siani - 1100 Skunk La. - Peconic
Name of Owner of Premises
IW.O.#TIOOI592831
Address
3) DoeR & restore Skunk La. . bell bole on the east side 2rass area and another bell hole on the west side 2rass
area. Both bell holes are aooroximatelv 950' south of Main Rd.
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. ~
9,nLt: ifJ~~~'
Signa re Appli t
04-25-02
Date
a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
publh: 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
hy the Town Clerk.
6) Tax Map: Section
. Block
. Lot
7) Starting Date:
Completion Date:
8) Work Schedule:
Phase Comoletion Date
Excavation...................................... ...................................
Facility Installation...............................................................
Backfill & Compaction.........................................................
Pavement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
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Tl00159283
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 $50,000 property damage.
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oennits: Basic Aoolication Fee ................. $25.00
AI. ~Service Connections excavations@ $20.00 ~ $ 20.00
No.
A2. ~Additional Excavations same service@ $10.00 ~ $10.00
No.
B. Excavations IS" in depth or less:
0-100 I.f. ~ $10.00
I.f. @ $O.IO~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. = $30.00
_1.f.@$0.30~$
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
I.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
permit.
. . .
TOTAL COST $55.00
Authorization is hereby granted to the Town Clerk aCthe Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk ~. 3". o~
Pennit Issued .$ - I - D )..
f-C)q- (J,;).
Date
Date
Permit No.
J7C,
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.
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APR. -2~' 0.2 (~HU) 1147
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PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
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COUNTY lK.J.JQ ~ -r;..h UI
MIS JOB~ DATE
NO. 1100/ SCJ 283 9- ',),-5" ZtJoz.
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SC GAS ~ES[GN PATC~ TEj516 758513S
KEYSPAN/lfAJ'
REQUEST FOR STREET OPENING PERMIT
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DEPARTMENT
GAS CONSTR.
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