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Date: 03/13/03
Transaction(s):
Name:
Clerk ID: L1NDAC
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 17304
Total Paid:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
17305
Subtotal
$1,069.50
$1,069.50
Internal 10: 71651
FILE'No.Oll 03/12 '03 12:09
10:
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PAGE 2/ 11
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File No.
TOWN Oh"OuTiroLD
81GHWAYDEPARTMENT
Peconic Laue
pec:onie, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR mGOW AY EXCAVATION AND Rl!:PAIR
-
,.
< PerDlit No.
REVISED
Ref./ffl00240617
APPLICATION IS IfEKEBY mad. to tile SaperialOlldeal .r ~Y' <ifill. Tow. .r S..tIoold f.r III. ;au_..r
a. E>:cavali4. Pannlt p.......t to CIuopter 13 .rllle C.... .flb. Towa oCSoulbold, 8"""11< eaallly, New V.rl<, .ad otIler
opp/leabl.I.ws, .rdl_.r replall... ror Ibu.",valioa .....ti. _...... The 'ppUelll .a.- to co..ply wilb aU
, .ppUeobl< law.. .nIi._ oodM oad replallo... a.d 10 permit ..IlI.ri.... laspecc.11 to mab _ry i.~...r lb.
J.bsit..
'rID! 0.. Tvoe
I) KEVSPAN ENERGY - GAS CONSTR. DEPT. -175 Eo OLD COUNTllY RD. - mCKSVILLEo NY 118111
N.... .r AppUo"l 4ddreu
8 R IIWi:.
2) lII:idce La.... Catebop.
N..... of Owo.. .fPremi...
/Ji(//)Lt 811./lJLl.
............. Lane.......Ct.... RlnllDdRd &. CrowD)aadLane-trenu. a total .f3.4151 in the prau arMS ofn.id
roads In Cuthwue te Inmll ni maI.1 ....d ",mUll: - mltaile road eroalh~.
...d.......
W.rk Deseripllolla'" Locatio. (Street N........, Homltl, C..... Streol)
(a) la...stra_aloca""wilbia75foetorlidalwod.lI1Is? .V.. No_X_
.Jfy,., otller Town permitlmay be rtrquired.
4) BuDder'. LlcOlllO'No.
Plamber's Lieease N.,
Eleelnclan'. Licea.. No.
OlIle'r
e'. License No.
Signal ot Appl" ant
2.06-03
Date
5) .) Altoeb pIol p!411 sbowiDl: loealltut of proposed tx""vallon ..d relaliollSllip to aclj olIIlag prelllises or
public streets or....... aad I1Vtnc a cIelaiIed descriptioa of layo.l of ....v.lI.n.
b) Altoeb all other aec-..y permts alld lice..... far lhis project.
c) Work covered by Chis appllcatlll1l may aol commeaee before Iss....ce of. mghw.y Enavalioa Pennll
by Che ToWll Cieri<-
6) Tax Map: SeelIon
7) startiog Date:
8) Work Scbedale;
. Block
. Lot
Completioa Date:
fIlaM! Comnlellon Date
)ta:uTadon . ...... ......, ............ ..... .... ........... ................... ........
'aaliCy _1Ia1lo..............",..................,......................,....
....ktllI & CQimp.~n....n. ................ ........, ........ ............... '0
'.vem.nt .ReplacomOllt.. ......... ........,... ........, ........ .....0....... ....
9) Vader wbleb .lIlboril)' is lbe appUcalioa made:
10) EltblUltecl Cost of PropOfed Work: S
11) Remark.,
FILE.No.Oll 03/12 '03 12:10
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FAX:
PAGE 3/ 11
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D-39
Page 1013
,
TtOO240617
12) In!:\lrance Covera~e: (Attach Copy)
a) Insurance Company.
b) Policy #
c) Swe wheIbor policy of cenification on file with the Highway Depanment:
d) CovOl1l&e required extended 10 the Town:
Bodily iJUury and property dlUllllge: $3oo,000/$S00,000 Bodily Injury. and $50.000 propetty damage.
13)~
a) Surety Bond Or Certified Check
ofS
b) Maintenance aonded provided: 2 Y""'" or
provided in the loral amounl
3 Y""'"
14) Fees for llllPlications and permils; Bash: AODlioatioll Fee ................. 525.00
AI. _1_!Service Conneerions excavalions@ $20.00 ~ Slll
A2. -'Addirional Excavations....., service@$IO.OO=$
No.
a. Excavations 18" in depth or IlISS:
0-100 U: =$10.00
1.f.@SO.IO=
Additional
C. Excavations 18" in depth 10 S' in depCh:
0-100 I.f. ~ $30.00
3.315 I.f.@$0.30=~
Additional
D. Excavation; S' in depth and over:
0-100 I.f. = $SO.OO
I.r. t@ SO.SO = $
Addirional
E.
No.
Urility Repair Excavarions @ $10.00 = $
Additional
Repairs same service @ $S.oo - $
F. Norice 10 public utilirios proofmUSl be provided and anaehed 10 this application prior to issuance of
pcmUl.
. . .
TOTAL COST 51.069.50..
..Cheek sent 1/24/03
Allthori2:ation i. hereby granre<l u> the To"" Cleik olthe To"" of Southol<! III i.... s Hishway Excavation PcrmillO:
KEYSPAN ENERGY DELIVERY in acoord&ncc with this application.
Received by the Town Cleric
Pen-nill....ed 3 /; 3 /J .3
.
3/13 /0"3
, Date
SuPERlNTEljDENT OF HIGHWAYS .
~~~w;t:~/
Peter W. urig
=//c:l~~
~ 0.../ )
Permil No.
02 1/0
~; PemUt apires one (1) Yt!l8r from Dalc of Issuance. No work to start without 48 hour notioe to the Superintendent of Highways.
Pennit mus~ be avaiblblc: tor inspection.
PAGE 5/ 11
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