HomeMy WebLinkAboutLands End Rd
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Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 01/31/03
Receipt#:
o
1 Permits
Check#: 17306
Total Paid:
Subtotal
$45.00
$45.00
Transaction(s):
~~
t'J;
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
IntemallD: 69959
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Permit No. --LJ .31
File No. 12!
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T1 00246036
APPLICATION IS HEREBY made to the Superintendent of Highways ofthe Town of South old for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of Southold. 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 of the
job site.
Print or Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) Lands End Road. Orient
Name of Owner of Premises
Address
3) Lands End Road - bellhole s/s l!rass area aODrox. 55' wlo the Vo Lands End Road and Latham Lane.
Orient. to install a !!as service to a new house
Work Description and Location (Street Number. Hamlet, Cross Street)
(a) Is construction located within 75 feet oftidal wetlands? "'Yes
"'If yes, other Town permits may be required.
No_X_
4) Builder's License No.
Plumber's License No.
Electrician's License No.
Signature of \\ppli
01-24-03
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 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 Schednle:
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
Tl00246036
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 $50,000 property damage.
13) Securitv:
a)
provided in the total amount
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
2 years or
3 years
14) Fees for aoolicatlOns and permIts: Basic Aoolication Fee................. $25.00
A 1. ~/Service Connections excavations @ $20.00 ~ $ 20.00
No.
A2. -----.J Additional Excavations same service @ $1 0.00 ~ $
No.
B. Excavations 18" in depth or less:
0-100 I.f. ~ $10.00
I.f. @ $0.1O~ $
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
E.
Utility Repair Excavations @ $1 0.00 ~ $
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 South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
r
Peter W. Harris
/-..19--tJ3
Date
Received by the Town Clerk
Date
Permit Issued
Permit No.
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
jAN,-23"'~3(THU) 14:12
BJ GAS DESIGN PATCH
TEL:516 7585136
p, 004
KEYSPANJ~A.r '.
REqUEST FOR S'TREI;T OPENING PERMIT
SKETCH
FC-8111.4
PERMIT
,NO.
LOCATION
REASON FOR
OPENING
o 'STATE
jrJ.rrA1L
REQUESTED
" BY
- APPROVED'
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