HomeMy WebLinkAbout620 Marlene Ln
Date: 04/24/02
Transaction(s):
Name:
Clerk 10: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16016
Total Paid:
J
~0
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
16016
Subtotal
$45.00
$45.00
Internal 10: 53401
Permit No.
/11
/7'1
.
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FileNo.
TOWN OF SOUTHOLD
IDGHWAYDEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICA TIONIPERMIT FOR HIGHWAY EXCAVATION AND REP AlR
Ref.#T100156997
APPLICATION IS HEREBY made to tbe Superintendent of Highways of tbe Town of Soutbold fOf tbe issuance of
an Excavation Permit pursuant to Chapter 83 oflhe Code oCtbeToWD olSonthold, Suffolk County, New York, and other
applicable laws, ordinances or regulations for tbe 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. - HICKSVlLLE. NY 11801
Name of Applicant Address
2) Mr. Michael Zahra - 620 Marlene Lane - Mattituck
Name of Owner of Premises
fW.O.#T100156997l
Address
3) ODeD & restore Marlene Lane - bell hole on the east side oaved area. aoorox. 575 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
*lfyes. other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
~"_'''k_'. ~
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Sign e of plica
04-18- 2
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
hy the Town Clerk.
6) Tax Map: Section
. Block
,Lot
7) Starting Date:
Completion Date:
8) Work Schedule:
Phase Comoletion Date
Excavation.............................................. ......... .... ..............
Facility [nstallation...............................................................
Backfill & Compaction.. ... .............. ......................................
Pavement Replacement. ...... .... ..... ....... ..... ......... ......... ....... ....
9) Under which anthority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
12) Insurance Coverace: (Attach Copy)
a) Insuraoce Compaoy:
b) Policy #
c) State whether policy of certification on file with the Highway Department:
d) Coverage required extended to the Town:
Bodily injury aod property damage: $300,000/$500,000 Bodily Injury, aod $50,000 property damage.
Tl00156997
13) Security:
a) Surety Bond or Certified Check
of$
b) Maintenaoce Bonded provided: 2 years or
provided in the total amount
3 years
14) Fees for aoolications aod oermits: Basic Aoolicatlon Fee................. $25.00
AI. ~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 I.f ~ $10.00
I.f @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 Lt. = 530.00
_l.f @$0.30=5
Additional
D. Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.f @ $0.50 ~ $
Additional
E.
No.
Utility Repair Excavations @$1O.00= $
Additional
Repairs same service @ $5.00 ~ $
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 Southald to issue a Highway Excavation Pennit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
1./- ~If-o)..
yf-d~ -0)
Date
Permit Issued 4- 'J ~ -0 1-
Permit No.
/71
Date
~: Pemrit 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 2 of3
\PR. -) i' .U1 (THUJ- U i 4 i
~u GAS U~SIGN ~ATGH nL~jb I~i~ljb
KEYSPAN/tfA.S'
REQUEST FOR STREET OPI;NING PERMIT
P UU2
Fval11.4
PERMIT
NO.
LOCATION
lEASON FOR
OPENING
W.OJPA
NO.
REQUESTED
BY
APPROVED
D STATE
D
. D SUFFOLK MX
COUNTY L!1J
FOREMAN
5., Uc1.
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~ DEPARTMENT
1/'.1;1 ->.c-#uiZ. GAS CONSTR. L ..z.)
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