HomeMy WebLinkAboutWells Rd Lot 7
Date: 04/23/02
Transaction(s):
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 16010
Total Paid:
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
16010
Subtotal
$215.80
$215.80
Internal 10: 53357
FileNo.
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Permit No.
TOWN OF SOUTHOLD
ffiGHW AY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICA TIONIPERMIT FOR HIGHWAY EXCA V A TION AND REPAIR
Ref.#T100149402
APPLICATION IS HEREBY made to the Superintendent of Highways uftbe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of tbe Code uftbe 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. Steven SkoDelitis - Lot #7 - Wells Rd. - SODthold
Name of Owner of Premises
(W.O.#T1001494021
Address
3) Ooen & restore - Wells Rd. - startinl! 20' east of Oaklawn Ave.. dil! a 636' trench easterlv in the north side
I!rass area to installl!as main.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet oftidal wetlands? *Yes No
*Ifyes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
ure of pplic t
04-1 -02
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) Startiug Date:
Completion Date:
8) Work Schedule:
Phase Comoletion Date
Excavation.............. ..................................................... ......
Facility Installation................ ...............................................
Backfill & CompactioD.........................................................
Pavement Replacement.......... .... ... ..... ... ......... .... ............ .......
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
Tl00149402
12) Insurance Covera.e: (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 $50,000 property damage.
13) Securitv:
a)
provided in the total amount
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
2 years or
3 years
14) Fees for aoolications and oermits: Basic ADolication Fee..... _........ ,.. $25.00
AI. _/Service Connections excavations @ $20.00 = $
No.
A2. _/Additional Excavations same service@$1O.00=$
No.
B. Excavations 18" in depth or less:
0-100 l.f. ~ $10.00
l.f. @ $0.10 ~ $
Additional
C. Excavations IS" in depth to 5' in depth: 636'
0-100 l.f. ~ $30.00
536 l.f. @ $0.30 ~ $ 160.80
Additional
D. Excavations 5' in depth and over:
0-100 l.f. ~ $50.00
l.f. @ $0.50 ~ $
Additional
Utility Repair Excavations@ $10.00 ~ $
E.
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 $215.80
Authorization is hereby granted to the Town Clerk of the Town of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPERINTENDENT OF HIGH
TOWN.~ S TH D NE .
(~ e
Peter W. Harris
Received by the Town Clerk tj-ri/OJ.-b;U
Date
Permit Issued '1./ -.z.,.D -c ;;... Permit No.
V~/tj-t1d
Date
j7lL
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 20f3
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.OCATION
3J GAS ~ES[G~ PATCP. TEL 5:6 7585136
KEYSPAN!G-U
REQUEST FOR STREET OPENING PERMIT..
o STATE
O SUFFOLK
COUNTY
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W.OJPA
NO.
IEQU~8TED
BY
APPROVED
SK~TCH
DEPARTMEN A
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