HomeMy WebLinkAbout685 Orchard St
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ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #171
Key, Span Energy- Gas Cant Dept
175 E Old County Rd
Hicksville, NY 11801
Received $ 45.00
1 - Permits on 04/11/2002.
Thank you.
Permit No. /7/
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FileNo. /7/
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100151303
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South old for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the TOWD 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. Garv Bruckner - 685 Orchard St. New Suffolk
Name of Owner of Premises
CW.O.#T1 00151303)
Address
3) ODen & restore a bell hole on the south side of Orchard St.. at the southwest corner of 2nd 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.
Other Trade's License N
e Applic
04- 5-02
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) 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: $
11) Remarks:
D-39
Page 1 of3
(2) 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 propetty damage: $300,000/$500,000 Bodily Injury, and $50,000 propetty damage.
Tl00151303
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
(4) Fees for aoolications and oermits: Basic Aoolication 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 l.f. ~ $10.00
If.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. = $30.00
_l.f. @ $0.30 ~ $
Additional
D. Excavations 5' in depth and over:
0-100 l.f. ~ $50.00
l.f. @$0.50~$
Additional
E.
Utility Repair Excavations@ $10.00 ~ $
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 this application.
Peter W. Harris
Received by the Town Clerk
rj-ID~02.-
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Date
Permit Issued 1.../ - / / - 0 z.
Date
Permit No.
(71
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
APR,-05'02(FRI) 12:10
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PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
.REQUESTED
BY
APPROVED
SKETCH
BU GAS DESIGN PATCH
p, 002
TEL:516 7585136
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
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