HomeMy WebLinkAbout36960 Route 25
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Permit No. I COO
File No. 1(00
TOWN OF SOUTH OLD
HIGHWAY DEPARTMENT RUSH
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATlONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.# -110 () 1~.8~ 2
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold 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 tomply with all
applkable laws, ordinantes, codes and regulations, and to permit authorized inspectors to make netessary inspections of the
job site.
Print or Tvpe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applinnt Address
2) 36960 Main Rd. - Cutchoene - 'IrJ.J... c..ojdj~ -;J).e--n~
Name of Owner of Premises Addr
Work Desl.:ription and Loution (Street Number, Hamlet, Cross tree
3) 0 en & restore Skunks Lane. bell hole in the east side aved area.
(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.
~
Signatn of Applicant
02-07-02
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 the Town Clerk.
6) Tax Map: Sectiou
, Block
,Lot
;'/8/02-
.
7) Starting Date:
:l{ pjlo 2-
Completion Date:
8) Work Schedule:
Phase Comoletion Date
Extavation .........................................................................
Facility Installation........................................................... ....
Backfill & Compattion....... ...... ........................ ....................
Pavement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
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w.o. #TI001.~.q~.;?
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: $300,0001$500,000 Bodily Injury, and $50,000 property damage.
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for avvlicalions and vermits: Basic Aoolication Fee................. $25.00
AI. -L-/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
IJ.@ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
D. 0-100 I.f. = $30.00
_1.f. @ $0.30 ~ $
Additional
E. Excavations 5' in depth and over:
0-100 1.f. ~ $50.00
1.f. @$0.50~$
Additional
F.
Utility Repair Excavations @ $10.00 ~ $
No.
Repairs same service @ $5.00 = $
Additional
G. 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.
DENT OF HIGHWAYS
T~~
Peter W. Harris
Received by the Town Clerk~
A L I. A . 'Dale ~ lo
Permit Issued ~ Permit No. 0
.,;;- g'-O-:J..
Date
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.
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KEYSPAN ENERGY FIELD SKETCH
FC-2555.5-SS
Work Order # Street Name S)eurJll..<i
Town C-1A7Cfh&lA.,o Grid # 100-5(' Overall Footage
t/l/IJp Cross Street~
Prepared by C.
-fr He 14512 /5 f1 Cc;RNei2 J-IOiA.5.9
,
AN 0 -n-i€- r1 Of) /lt55 I S
3(; 9hO !Ylfll';ll f?~lId. i-
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\I.P~ 0
\
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Old You Show:
o Street Name 0 North Arrow
o Cross Street 0 Pipe Diameter
Location/Dimension:
o Couplings 0 Tees
o Valves 0 Reducers
o Pipe Material
o Offsets Labeled
o Covers
o Anodes/Test Stations
o End of Main
o Main off Curb in Feet
o Anodes/Test Stations
o Offsets
.
. '.
Date: 02/08/02
Transaction(s):
Name:
1 Permits
Cash#: 15641
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Clerk 10: L YNDAB
Town Of Southold
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
15641
Subtotal
$45.00
$45.00
InternallD: 49316