HomeMy WebLinkAbout425 South Harbor Rd
Date: 02/27/03
Transaction(s):
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
1 Permits
Check#: 1048
Total Paid:
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
1048
Subtotal
$216.00
$216.00
Internal 10: 71171
Date: 02/20/03
Transaction(s):
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Check#: 1048
2J1
fJl
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
Receipt#:
Total Paid:
1048
Subtotal
$216.00
$216.00
Internal JD: 70924
pernntNo'02 3 r
FileNo.
TOWN OF SOUTHOLD
IDGHWAYDEPARTMENT
Peeonie Lane
Peeonie, New York 11958
(631) 765-3140
-
APPLICATION/PERMIT FOR IDGHW AY EXCAVATION AND REPAIR
Ref.#T1 00245656
APPLICATION IS HEREBY made to the Superintendent of Highways orthe Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code oftbe Town of Southold, Suffolk County, New Yor14 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
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 425 South Harbor Road, Soutbold
Name of Owner of Premises
Address
South Harbor Road - a 570' treuch iu the e/s erass area star/iue at the i/o of S.R. #25 (Maiu Road). Southold. to
install a l!as main and 28S service to house #425
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S feet of tidal wetlands? *Yes
*Ifyes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Other T
re of pplie
02-06-03
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 otler 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 Towu Clerk.
6) Tax Map: Sectiou
,Block
. Lot
7) Startiug Date:
Completiou Date:
8) Work Schedule:
Phase Comoletion Date
Excavation -::::::::.................................................................
Facility Installation...............................................................
BacId111 & 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 $50,000 property damage.
TI00245656
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for annlications and nermits: Basic ADDlication Fee................. $25.00
AI. _l_/Service Connections excavations@$20.00"" $20.00
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 I.f. ~ $30.00
470 I.f. @ $0.30 ~ $141.00
Additional
D. Excavations 5' in depth and over:
0- I 00 I.f. ~ $50.00
I.f. @$0.50~$
Additional
E.
No.
Utility Repair Excavations @ $1 0.00 ~ $
Additional
Repairs same service @$5.00= $
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
. . .
TOTAL COST $216.00
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.
TO
)
Peter W. Harris
,:://~,3
Date
Received by the Town Clerk 0{ / ;/ tJ It> 3
;1/;;'0/0 a
Permit No.
&3;;
Permit Issued
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 20f3
FEB, -05' 03 (WED) : 1: 27
3D GAS DESISN PATCH TEL:5!6 7585136
j<EYSPAN.i<<AS
REQUEST FOR STfIEEET OPENING PERMIT
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