HomeMy WebLinkAbout550 Marlene Ln
. .
Date: 04/24/02
Transaction(s):
Name:
Clerk 10: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16016
Total Paid:
S
*\1
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hlcksville, NY 11801
16016
Subtotal
$45.00
$45.00
Internal 10: 53402
Permit No.
/7S
/75'
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICA TlONIPERMIT FOR HIGHWAY EXCA VA TION AND REPAIR
Ref.#T100156986
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Soutbold fo.. the issuance of
an Excavation Permit pursuant to Chapter 83 of tbe 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 Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) Mr. Michael Zahra - 550 Marlene Lane - Mattituck
Name of Owner of Premises
IW.O.#TIOOI569861
Address
3) ODeD & restore Marlene Lane - bell hole on the east side oaved area. aoorox. 500 feet 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
*Ifyes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
e nf
04-18-
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) 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:
D-39
Page 1 of3
Tl00156986
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 $50,000 property damage.
13) Security:
a) Surety Bond or Certified Check
of$
b) Maintenance Bonded provided: 2 years or
provided in the total amount
3 years
14) Fees for aoolications and oermits: Basic Annlication Fee ................. $25.00
A 1. ~Service 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.f. ~ $10.00
I.f. @$O.IO=$
Additional
C. Excavations IS" in depth to 5' in depth:
0-100 Lf. = $30.00
_1.f.@$0.30~$
Additional
D. Excavations S' in depth and over:
0-100 1.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 $45.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Peter W. Harris
Received by the Town Clerk i/ - c? 1./ - 0 2-
"1_ ';. '1-0 '1- Date
'(-93-o~
Date
Permit Issued
Permit No.
/7"-
~: 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.
D-39
Page 20f3
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KEYSPAN/tfAJ"
REQUEST FOR STREET OPENING PERMIT
F~'" ..
PERMIT
NO.
.OCATION
EASON FOR
:)PENlNG
W.OJPA
NO.
EQUESTED
eV
o STATE
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NASSAU
COUNTY
o
FOREMAN
DEPARTMENT
GAS CONSTR. L.. . }
IPPROVED
iKETCH
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