HomeMy WebLinkAboutHarper Rd
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #168
Key, Span Energy- Gas Cant Dept
175 E Old County Rd
Hicksville, NY 11801
Received $ 565.50
1 - Permits on 03/28/2002.
Thank you.
FileNo.
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Permit No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICA TlON/PERMIT FOR HIGHWAY EXCA V ATlON AND REPAIR
Ref.#T100140400
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 orthe 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 or the
job site.
Print or TVDe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) Mr. Robert Jester Harper Road
Name of Owner of Premises
IW.O.#T1001404001
Address
3) ODen & restore a bell hole & 393' trench east in the nls Ilrass area of Jernick La.. crossinll Grillonis Path. A trench north
on Grh!Oois Path for 610' in the els e:rass area crossinll Peck PI.. a trench east for 535' 00 the s/s of Harner Rd. W.. a 190'
trench on Wells Ave.. crossin!:! HarDer Rd. W.. and a 25' trench in the s/s I!rass area of Peck PI.
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.
of A
03-19-02
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: $
II) Remarks:
D-39
Page 1 of3
Tl00140400
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 $50,000 property damage.
13) Security:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic AuuIication Fee ................. $25.00
AI. ----L-/Service Connections excavations @ $20.00 = $ 20.00
No.
A2. _/Additional Excavations same service@ $10.00 ~ $
No.
B. Excavations IS" in depth or less:
0-100 l.f. ~ $10.00
1.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth: 1,753'
0-100 Lf. = $30.00
1.635 l.f. @ $0.30 ~ $ 490.50
Additional
D. Excavations 5' in depth and over:
0-100 1.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 $565.50
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation 'Pennit to:
KEYSPAN ENERGY DELIVERY in accordance with this application. '
Permit Issued
3 /02././6 )-
3/ ~1,/tJ;"'"
Date"
::?-~-().:l...
Date
Received by the Town Clerk
Permit No.
/~8
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 2of3
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SU GAS UESIGN PATCH
TEL:516 7585136
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