HomeMy WebLinkAbout17250 1st St
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, NewYorl< 11971
Phone: 631-765-1800
RECEIPT #163
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Received $ 45.00
1 - Permits on 03/12/2002.
Thank you.
Permit No.
/fp3
/(p3
r~
~
FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100140348
APPLICATION IS HEREBY made to the Superintendent of Highways uftbe Town of Soutbold for the issuance of
an Excavation Permit pursuant to Chapter 83 urthe Code urtbe Town of South old, Suffolk County, New York. and other
applicable laws, ordinances or regulations for tbe 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 ufthe
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. Ted Victoria - 17250 I" St. - New Suffolk
Name of Owner of Premises
fW.O.#T1001403481
Address
3) OoeD & restore Main St. - bell hole on the north side l!rass area aooroximatelv 10 feet west of 1 st Street
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.
rtL d.~fu"A :i.h'
o ~ siglltn;;r;;:;t:;
03-07-02
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 tbe Town Clerk.
6) Tax Map: Section
,Block
, Lot
7) Starting Date:
Completion Date:
8) Work Scbedule:
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
Tl00140348
12) Insurance Cover..e: (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 annlications and permits: Basic Aoolication Fee ....,... ......... $25.00
AI. ~Service Connections excavations @ $20.00 = $ 20.00
No.
A2. ~Additional Excavations same service@$10.00=$
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 l.f. = $30.00
_1.f.@$0.30~$
Additional
D. Excavations 5' in depth and over:
0-100 I.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 $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 appHcatioo.
SUPERINTENDENT OF mGHW A YS
T~&~~
Peter W. Harris
Received by the Town Clerk ..J /11 J (J 2-
/ / Date
Permit Issued..3 II 0 2- Permit No.
. .
03- 11-6~
Date
/ G:,~3
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hOUT notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39
Page 2 0(3
~IAK.. -\11 U.L\!NU} U~:qq
au ~ft~ UD~I~~ rftl~N
IDL'''10 1"0"100
Fc-ell1.4
PER IT
NO.
LOCATION
REASON FOR
OPENING
W,O"iPA
NO.
REQUESTED
BY
, APPROVED
SKETCH
, .
!J1/f;tJ
KEYSPAN/~A.r
REQUEST FOR STREET OPENING PERMIT
D S~ATE
FOREMAN
? II DEPARTMENT
, V);; ...JUlu72- GAS CONSTR. L..z' .)
-
_21'ffl
( ~ c:.. lc'A.b/,IJA'I J
.Y':
;j (){,UE-
r. uu I
IZI ..5O/,J.7Jl.ct.l:J
..;...r./~
~'..2'i':J ~/O/~.5C) ~ J
-i 10' h" N
.
,
<N4
'1
s
I~
Ir..:.
I""
r
I~
I~
I ~
Ii
I~
I~
I
~_I
T
\cq
~,
-
-