HomeMy WebLinkAbout3870 Stillwater Ave
Date: 01/31/03
Transaction(s):
1 Permits
Check#: 17280
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
Total Paid:
fYJ(P
t;}
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: L1NDAC
17280
Subtotal
$75.00
$75.00
InternallD: 69961
pernntNo'd 3~
FileNo.
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TOWN OF SOUTH OLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#TI00240076
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South old for the issuance of
an Excavation Permit pursuant to Chapter 83 or the Code ofthe Town of South old, Suffolk County, New York, and other
applh:able 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) 3870 Stillwater Avenue, Cutchogue
Name of Owner of Premises
Address
Stillwater Ave - bellhole and 40' trench in the els l!rass area aoorox. 100' nlo Track Avenue. Cutcho2'ue. to
install a 2'as main and l!as service.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 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.
of Appl cant
1-16-03
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 the Town Clerk.
6) Tax Map: Section
,Block
, Lot
7) Startiog Date:
Completion Date:
8) Work Schedule:
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:
0-39
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 $50,000 property damage.
Tl00240076
13) Security:
a)
b)
Surety Bond_
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic Aoolication Fee.............. .,. $25.00
A 1. _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 If. ~ $10.00
1f.@$0.10~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 If. ~ $30.00
_If. @$0.30~
Additional
D. Excavations 5' in depth and over:
0-100 If. ~ $50.00
If. @$0.50~$
Additional
E.
No.
Utility Repair Excavations @ $10.00 ~ $
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 $75.00
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.
SU..~D. ENT OF HIGHWAYS
T~ ~&~RK
Peter W. Harris
Received by the Town Clerk / ) 3~ 3
/ / Date
Permit Issued I .3 / I /);; Permit No.
J
Note: Permit expires one (l) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
/ - JY1- i'J.3
Date
cZ3,6
D-39
Page 2 of3
KEYSPAN ENERGY KEYSI?AN!,fA'-5
REQUEST FOR STREET OPENING PERMIT,
JAN. 8.20~3 3:06PM
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