HomeMy WebLinkAbout4170 Peconic Bay Blvd
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #169
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Received $ 45.00
1 - Permits on 03/28/2002.
Thank you.
Permit No.
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TOWN OF SOUTHOLD
lliGHW AY DEPARTMENT
Peconic Lane
Peeonie, New York 11958
(631) 765-3140
APPLlCA TIONIPERMIT FOR HIGHWAY EXCA V A TION AND REPAIR
Ref.#T100144919
APPLICATION IS HEREBY made to the Superintendent of Highways ortbe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 ortbe Code ortbe 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 ortbe
job site.
Print or Tvoc
1) KEYSPAN ENERGY -GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD.-HlCKSVlLLE. NY 11801
Name of Applicant Address
2) Mr. Joseoh Chisholm 4170 Peeonie Bav Blvd.
Name of Owner of Premises
Laurel
Address
(W.O.#TlOOI449191
3) Ooen & restore Peconic Bav Blvd. - bell hole on sls oaved area. aoorox.. 395' nlo Delmar Dr.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? "'Yes No
"'If yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
.
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
hy the Towo Clerk.
6) Tax Map: Section
,Block
,Lot
7) Startiog Date:
Completion Date:
8) Work Schednle:
Phase ComDletion 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
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 $50,000 property damage.
Tl00144919
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for applications and permits: Basic Application Fee.............. ... $25.00
AI. ~Service Connections excavations @ $20.00 ~ $ 20.00
No.
A2. -.I Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 l.f. ~ $10.00
l.f.@ $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 3/;).& /0 )..
Permit Issued 3/02 Ii"/o do.
3-~-o;.)..
Date
Date
Permit No.
/b9
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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