HomeMy WebLinkAbout400 Hill Rd
.
Town Of South old
P.OBox1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 01/31/03
Transaction(s):
1 Permits
Check#: 17295
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: L1NDAC
/
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Receipt#:
Total Paid:
17295
Subtotal
$144.00
$144.00
InternallD: 69960
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Permit No. r; 3 )
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
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Peconic, New York 11
(631) 765-3140
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APPLICATION/PERMIT FOR HIGHWAY EXCA /? /./
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APPLICATION IS HEREBY made to the Superintendent of High t/rrer rt'1I ~ .
an Excavation Permit pursuant to Chapter 83 or the Code or the Town OrSOl ,.../ / I
applicable laws, ordinances or regulations for the excavation herein describel.4 l ("'AI 4ft( tth / / ~e
applicable law" ordinance" codesand ..gulation" and to permit authorized / 11/5 /5 .) u 7 v / . /~
jObSi~k~ ~e
Print or Tvoe t2 6/.e ok tJl a.e 'fL
1) KEYSPAN ENERGY-GAS CONSTR. DEPT. -175E.OLDC Co,fee! H~at:r5 uJ/'f4 .€
Name of Applicant { -, / /
Os h-r (Yla..:ter/tUS.
2) 400 Hill Road, Sonthold
Name of Owner of Premises
Hill Road - bellhole tIs of intersection of Harner Road. trench across intersection and a 330' trench in the nfs
erass area to to install a 2as main and I!as service to #400.
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 Trade's License No.
Signatnre of Ap cant
01-21-03
Date
S) 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) Starting 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 Co,t of Proposed Work: $
11) Remarks:
-
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Permit No. '7 3 )
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FileNo.
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TOWN OF SOUTH OLD
HIGHWAY DEPARTMENT
Peconic Lane
PecoDic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100241533
APPLICATION IS HEREBY made to the Superintendent of Highways orthe 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 orthe
job site.
Print or Tvue
I) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - HlCKSVILLE. NY 11801
Name of Applicant Address
2) 400 Hill Road, South old
Name of Owner of Premises
Address
Hill Road - bellhole cIs of intersection of Harner Road. trench across intersection and a 330' trench in the n/s
I!rass area to to install a I!as main and I!as service to #400.
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.
Other Trade's License No.
Signature of Ap cant
01-21-03
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
hy the Towu Clerk.
6) Tax Map: Section
, Block
, Lot
7) Startiug 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:
D-39
Page t of3
Tl00241533
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
Ii) 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 $50,000 property damage.
I 3) Securitv:
a)
Ii)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic AODlication 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
1.[ @ $0.10 ~
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.[ ~ $30,00
230 1.[ @ $0.30 ~ $69.00
Additional
D. Excavations 5' in depth and over:
0-100 1.[ ~ $50.00
1.[ @ $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 $144,00
Authorization is hereby granted to the Town Clerk of the Town of South old to issue a Highway Excavation Permit to:
KEYSP AN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk I fa 0 / () 3
Permit Issued II ~ I/O ~
I~ d9-tJ.3
Date
Permit No.
~~b
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.
D-39
Page 20f3
JAN, ~li' 03'(FRI) 16:40 BU GAS DESIGN PATCH TEL:516 i585136 p, 002
KEYSFAN
REQUEST FOR STFIEET OPENING PERMIT
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