HomeMy WebLinkAbout3965 Mill Ln
Date: 02/26/03
Transaction(s):
1 Permits
Check#: 17296
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
K ~~1J
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
17296
Subtotal
$45.00
$45.00
InternallD: 71116
Permit No.
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICA nONIPERMIT FOR HIGHWAY EXCA V A nON AND REPAIR
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!<.Ef" .# 2-'13 974
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 orSonthold, 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. - HICKSYlLLE. NY 11801
Name of Applicant Address
2) 3965 Mill Lane. Mattituck
Name of Owner of Premises
Address
3) Mill Lane - hellhole e/s erass area aoorox. 271' nlo Wickham Ave.. Mattituck. to install a eas service to
#3965
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? "'Yes
"'If yes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Tra
Signature f Ap icant
01.22-03
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 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:
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Tl00243974
] 2) 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 $50,000 property damage.
13) Securitv:
a)
provided in the total amount
b)
Surety Bond_
of$
Maintenance Bonded provided:
or Certified Check
2 years or
3 years
14) Fees for aoohcatIons and oemllts: Basic Aoolication Fee.............. ,.. $25.00
A 1. ~/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 If. ~ $]0.00
If.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 If. ~ $30.00
_If @$0.30~$
Additional
D. Excavations 5' in depth and over:
0-100 If. ~ $50.00
If.@ $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 0( J J "" I () ?
/. /1'> Date'
Permit Issued Q I ~L,p f ~ 3 Permit No.
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.
/
:;J 9- () 3
Date
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Page 2 of3
KEYSPAN ENERGY KEYSPAN/cfAJ" ,
REqUEST FOR STREET OPENING PER~IT
NO. 405
P.6
", '
JAN.17.2003 12:25PM
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PERMIT,
NO.
LOCATION
REASON FOR
OPENING
, W,OJPA
NO.
REQUESTED
. BY
. APPROVED
SKETCH
, '
D 'STATE
DEPARTMENT
GAS CONSTR. L ..:z: ' )
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