HomeMy WebLinkAbout1090 Latham Ln
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold. New York 11971
Phone: 631-765-1800
RECEIPT #166
Key. Span Energy- Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Received $ 55.00
1 - Permits on 03/28/2002.
Thank you.
Permit No.
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATIONIPERMIT FOR IDGHWAY EXCAVATION AND REPAIR
Ref.#T100148524
APPLICATION IS HEREBY made to the Superintendent of Highways ortbe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 or 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
1) KEYSPAN ENERGY -GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD.-HICKSVlLLE. NY 11801
Name of Applicant Address
2) 1090 Latham La. - Orient
Name of Owner of Premises
Address
3) ODeD & restore Latham Lane. bell hole on the s/s erass area & a test hole on the nls Daved area aoorox..
200' elo Lands End Rd. in Orient.
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 No.
re of plica
03-25-02
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 Tnwn 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
Tl00148524
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
h) 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 $50,000 property damage.
13) Securitv:
a)
Ii)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oennits: Basic Apolication Fee.............. ... $25.00
AI. ..LService Connections excavations @ $20.00 ~ $20.00
No.
A2. -.L Additional Excavations same service @ $10.00 ~ $10.00
No.
B. Excavations 18" in depth or less:
0-100 l.f. ~ $10.00
l.f. @ $O.IO~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 l.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 @ $1 0.00 ~ $
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 $55,00
Authorization is hereby granted to the Town Clerk of the Town of Southald to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk al.ufo",
, I... / Date
Permit Issued <3~/o:l..
. /,/6tC1f,4L.
Note: Permit expires one (1) year from Date of Issuance.
Permit must be available for inspection.
3-- .;l ~ -0 ;L,
Date
Permit No.
/b~
No work to start without 48 hour notice to the Superintendent of Highways.
D-39
Page 2 of3
MAR. ~25' 02.!MON) 0953
3C GAS DES:GN PATCH
TEL 516 7585136
? C 2 2
KEYSPAN/~AJ'
REQUEST FOR STREET OPENING PERMIT
F~1".4
PERMIT
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LOCATION LIf
REASON FOR ..
OPENING ftrfJA>
W.OJPA
NO.
REQUESTED
BY
lA-
, ~ DEPARTMENT
I/)/{ ...Jb. ua. GAS CONSTR. L.%, l
APPROVED
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RJL~cY
'INSTALLATION
NO HEAt
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