HomeMy WebLinkAboutGrathwohl Rd
Date: 03/10/03
Transaction(s):
Name:
Clerk 10: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 1125
Total Paid:
)
qD
~~
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
1125
Subtotal
$123.00
$123.00
InternallD: 71475
Permit No.
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#TI00257611
APPLICATION IS HEREBY made to the Superintendent of Highways or the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of the 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 or the
job site.
Print or TVDe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 Eo OLD COUNTRY RD. - HICKSVILLE, NY 11801
Name of Applicant Address
2) Graithwohl Rd, New Suffolk
Name of Owner of Premises
Address
Graithwohl Road - bellhole and a 260' trench in the els 2rass area nlo New Suffolk Ave.. New Suffolk. to install
a 2as main and 2as service ti house #15305
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*Ifyes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
~
e of Ap
03-03-03
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 Towu Clerk.
6) Tax Map: Sectiou
, 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: $
1 t) Remarks:
D-39
Page 1 of3
Tl00257611
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 ao"hcatlOns and "enmts. Basic ADDlication Fee................. $25.00
A 1. ~ l_/Service Connections excavations @ $20.00 = $20.00
A2. _I Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 1.[ ~ $10.00
I.[@ $0.10 ~
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I. [ ~ $30.00
160 1.[ @ $0.30 ~ $48.00
Additional
D. Excavations 5' in depth and over:
0-100 Lf. ~ $50.00
1.[ @$0.50~$
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 $123.00
Authorization is hereby granted to the Town Clerk ofthe Town of South old to issue a Highway Excavation Permit to:
KEYS PAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk
Perrnit Issued 3 to 10 3
I /
3//0/03
SU~TOF HIGHWAYS
TO 0~21~
~Z-?
Permit No.
at! s-'
Date
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highv.rays.
Permit must be available for inspection.
D-39
Page 2 of3
MAR,-03'03(MONI10:52
BJ GAS DESIGN PATCH TEL:516 i585136
KEYSPA'Y"'AJ
REQUEST FOR STREET OPENING PERMIT
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DAl'E OF
OPENINIl
APPROVED
CEPARTMEN _
GASCONSTR.~.."'-: JA1C;I/)fI<IL "/'S/7751-SI4c -
DATE
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