HomeMy WebLinkAbout90 Country Club Dr
Date: 03/04/02
Transaction(s):
Name:
Clerk 10: L1NDAC
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 15756
-it /~ 2-
Key, Span Energy - Gas Cant Dept
175 E Old County Rd
Hicksville, NY 11801
Receipt#:
Total Paid:
15756
Subtotal
$45.00
$45.00
Internal 10: 50598
Permit No. / ~~
File No. I (p l-J
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
~
~
APPLICA TION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100139451
APPLICATION IS HEREBY made to the Superintendent of Highways urtbe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code uftbe 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 netessary inspections of the
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY ll801
Name of Applicant Address
2) Mr. Robert Kennev - 90 Conntrv Clnb Dr.
Name of Owner of Premises
Cutchol!ue
Address
fW.O.#T1001394511
3) Ooen & restore a bell hole on the north side erass area ofCountrv Club Dr.. aooroximatelv 150 feet west of
Moores Lane.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required.
4) Builder's License No.
Plumber's License No.
Electrician's License No. Other Trade's License No.
c;r~:a~'
02-27-02
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 Towo Clerk.
6) Tax Map: Section
,Block
,Lot
7) Startiog Date:
Completion Date:
8) Work Scbednle:
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 $50,000 property damage.
Tl00139451
13) Security:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for applications and permits: Basic ADDlication Fee................. $25.00
A!. ----L-/Service Connections excavations @ $20.00 ~ $ 20.00
No.
A2. _/ Additional Excavations same service @ $10.00 = $
No.
B. Excavations IS" in depth or less:
0-100 1.f. ~ $10.00
1.f.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. ~ $30.00
_1.f. @$0.30~$
Additional
D. Excavations 5' in depth and over:
0-100 I.f. ~ $50.00
1.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 application.
Peter W. Harris
Received by the Town Clerk 3/ 'i /D;2..;>
I / Date
Permit Issued -3 ~ / 0,), Permit No.
.
~6-01-CJ~
Date
I~ cb
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
FEB.-2i'02(WED) Oi:49
.' .
BU GAS DESIGN PATCH TEL:516 i585136
KEYSPAN/~A.r
REQUEST FOR STREET OPENING PERMIT
P. 006
~11U
PERMIT.
NO.
LOCATION
REASON FOR
OPENING
W.OjPA
NO.
REQUESTED
BY
. APPROVED
o STATE
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