HomeMy WebLinkAbout5115 New Suffolk Rd
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #164
Key, Span Energy- Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Received $ 45.00
1 - Permits on 03/18/2002.
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 HIGHWAY EXCA V A TION AND REPAIR
Ref.#T100143413
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South old for the issuance of
an Excavation Permit pursuant to Chapter 83 oftbe 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 orthe
job site.
Print or Tvoe
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) Mr. Tom Gleason - 5115 New Suffolk Rd.IROWl - New Suffolk
Name of Owner of Premises Address
IW.O.#TI001434131
3) Ooen & restore - Old Harbor Rd. - bell hole on the south side oaved area aooroximatelv 135 feet southeast
of New Suffolk Rd.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? .Yes No
-[(yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other Trade's Li:; :o~~ .
riA ~ Signature 0 'APPl~
03-08-02
Date
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.
5)
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 tbe Town Clerk.
6) Tax Map: Section
. Block
. Lot
7) Starting Date:
Completion Date:
8) Work Scbedule:
Phase Comoletion Date
Excavation............. ....................................................... .....
Facility Installation................. ..............................................
Backfill & CompactioD.........................................................
Pavement Replacement.............. ... .............. ......... ... ...... ... .....
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
II) Remarks:
D-39
Page 1 of3
TI00143413
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 avvlications and vermits: Basic ADDlication Fee............. .... $25.00
AI. -1-fService Connections excavations @ $20.00 ~ $ 20.00
No.
A2. _I Additional Excavations same service @ $1 0.00 ~ $
No.
B. Excavations 18" in depth or less:
0-100 I.f. ~ $10.00
I.f.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. = $30.00
_I.f. @$0.30~$
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
I.f. @ $0.50 ~ $
Additional
Utility Repair Excavations @ $10.00 ~ $
E.
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 Southald to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance wlth this application.
S~~ENT OF HIGHWAYS
TO /U7J)N~
Peter W. Harris
Received by the Town Clerk
Permit Issued 3/lf/();l..J
..3/ I sic> 2.---
..3-/3-(),;).
Date
Date
Permit No.
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Note: Permit expires one (1) year from Date of Issuance. No work to start wlthout 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
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Page 2 of3
MAR,' -08~ Ot (FRI) 11: 12
P. 002
BU GAS DESIGN PATCH TEL:516 i585136
KEYSPAN/&A .s
REQUEST FOR STREET OPENING PERMIT
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