HomeMy WebLinkAbout1065 Kings St
Date: 04/24/02
Transaction(s):
Name:
Clerk ID: L1NDAC
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 16021
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
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Receipt#:
Total Paid:
16021
Subtotal
$45.00
$45.00
Internal 10: 53399
Permit No. I 7 3
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File No. / 7,3
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TOWN OF SOUTHOLD
IDGHWAYDEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR IDGHWAY EXCAVATION AND REPAIR
Ref.#T100157767
APPLICATION IS HEREBY made to the Superintendent of Highways oftbe Town of Soutbold for tbe issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of Southold, Suffolk County, New York, aDd 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 TVDe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) David ThomDson - 1065 Kines St. - New SDffolk
Name of Owner of Premises
IW.O.#T100157767\
Address
3) ODeD & restore a bell hole on the west side oaved area of 2nd St.. aooroximatelv 50 feet north of Kim! St.
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.
OtherTrade's~ ~
~ 1. a~
Sign f plican
04-19-02
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 the TowD Clerk.
6) Tax Map: Section
. Block
. Lot
7) StartiDg Date:
Completion Date:
8) Work SchedDle:
Phase Comoletion Date
Excavation. ......... ......... ....... ............ ......... ..........................
Facility Installation........... ........ .... ................. ................ .......
Backfill & Compaction.........................................................
Pavement Replacement................... ......................................
9) UDder which authority is the applicatioD made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 0(3
Tl00157767
12) Insurance Covera.e: (Attach Copy)
a) Insurance Company:
h) 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 $50,000 property damage.
13) Security:
a)
h)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic Aoplication Fee................. $25.00
AI. ~/Service Connections excavations @ $20.00 ~ $ 20.00
No.
A2. -"Additional Excavations same service @$1O.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 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 @ $1 0.00 ~ $
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 tbis application.
Peter W. Harris
Received by the Town Clerk t/ 1;("/0 z..
Permit Issued 1/01'1/0 ~
y-.;z .3 - 0.2-
Date
Date
Permit No.
/73
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.
D-39
Page 2 of3
APRc-19:02:PR:: 1308
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PERMIT
NO.
LOCATION
REASON FOR
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NO.
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REQUEST FOR STREET OP~NING PERMIT
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