HomeMy WebLinkAbout725 White Eagle Dr
Date: 02/26/03
Transaction(s):
Town Of South old
P,O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 17296
Total Paid:
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
17296
Subtotal
$45.00
$45.00
Internal 10: 71115
permitNo.~
File No. d "1 [
f~
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCA V A TlON AND REPAIR
Ref.#Tl00243495
APPLICATION [S HEREBY made to the Superintendent of Highways of the Town of South old 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 inspedions 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) 725 White Ea.le Drive. Laurel
Name of Owner of Premises
Address
3) White Eaele Drive - bellhole cIs 2rass area aoorox. 107' s/o Condor Ct.. Laurel. to install a I!as service to
#725
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S feet of tidal wetlands? .Yes
*lfyes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's License No.
Signature 0 Ap
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) Startiog 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:
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 $50,000 property damage.
Tl00243495
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for avvlications 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 I.f. ~ $10.00
1.f.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f. ~ $30.00
_l.f.@$0.30~$
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
I.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 $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.
Received by the Town Clerk cl /~(, jo!J
~ / ;;D.!e
Permit Issued ..2 Jc, f) 7 Permit No.
, ,
(J/ -21-03
Date
clift
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 2 of3
Fo8111.4
PERMIT.
NO.
LOCATION --'1.
RI;ASON FOR /l . I' II
OPENING '-<()/J fJ Or--
W.OJPA
NO.
REQUESTED
.' BY
. APPBOVED
o STATE
KEY5PAN ENERGY NO. 405 P. 7
. KEYSPAN,hAS '.
REQUEST FOR STREET OPENING PERII.:1IT
. ~ $kmD(.,i
JAN.17.2003 12:25PM
NJs"fA. tL-
DEPARTMENT
GAS CONSTR. L ,;& . )
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