HomeMy WebLinkAboutLands End Rd Lot 15
Date: 03/10/03
Transaction(s):
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 1072
Total Paid:
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
1072
Subtotal
$45.00
$45.00
InternallD: 71474
Permit No.
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TOWN OF SOUTH OLD
HIGHWAY DEPARTMENT
Peconic Lane
Peeooie, New York 11958
(631) 765-3140
FileNo.
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T1 00246036
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of South old. 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
I) KEYSPAN ENERGY -GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD.-HltKSVILLE. NY 11801
Name of Applicant Address
2) Lot 15. Lands End Road. Orient
Name of Owner of Premises
Address
3) Lands End Road - bellhole s/s I!r8SS area aODrox. 55' wlo the i/o of Lands End Road & Latham Lane.
Orient. to install a 2as service.
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.
re oCAp
02-19-03
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 tbe 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: $
II) Remarks:
D-39
Page 1 of3
Tl00246036
12) Insurance Covera.e: (Attach Copy)
a) Insurance Company:
Ii) 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 $50,000 property damage.
13) Security:
a)
Ii)
Surety Bond.
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic ADDlication 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 Lf. ~ $10.00
Lf.@ $0.10 ~ $
Additional
C. Excavations IS" in depth to 5' in depth:
0-100 Lf. ~ $30.00 ~
_1.f. @ $0.30 ;
Additional
D. Excavations 5' in depth and over:
0-100 Lf. ~ $50.00
Lf. @ $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 South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
;rENDENT OF HIG
SOUTl)' N
WAYS
YORK
?::; \ 0 r5':J
Received by the Town Clerk.
..3' -/0 '63
Dae
Pennit Issued .3 -/0 -() ,;
Date
Pennit No.
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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
FROM
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