HomeMy WebLinkAbout1775 Indian Neck Ln
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Received $ 90.00
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #151
1-Permits on 12/21/2001.
Thank you.
t
Permit No.
ISI
/SI
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
Ref.#T100116043
FileNo.
APPLICATION/PERMIT FOR IDGHW AY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Higbways of the Town of South old for the issuance
an Excavation Permit pursuant to Chapter 83 oftbe 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 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) Roland Grant 1775 Indian Neck La.
Name of Owner of Premises
Peconic
Address
IW.O.#T1001160431
3) ODen & restore a bell hole on the els l!rass area of Indian Neck Rd.. and a 150' trench south in the e/s !!rBSS
for 150' startin!! aooroximatelv 375' slo Sorinl!' La.
Work Description and Location (Street Nnmber, Hamlet, Cross Street)
(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.
Other Trade's License N~~
94r-' ;'?=s.&o
Signat e 0 ~pplic t
12-17-01
Date
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.
5)
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 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
Tl 00 116043
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 $50,000 property damage.
13) Security:
a)
b)
Surety Bond
of$
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
AI. ~Service Connections excavations@$20.00=$ 20.00
No.
Al. ----1Additional Excavations same service@$10.00=$
No.
B. Excavations 18" in depth or less:
0-100 Lf ~ $10.00
Lf @$0.1O~$
.i'
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 Lf ~ $30.00
150 Lf @ $0.30 ~ $15.00
Additional
D. Excavations 5' in depth and over:
0-100 Lf. ~ $50.00
Lf @ $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 $90.00
Authorization is hereby granted to the Town Clerk of the Town of South old to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPERINTENDENT OF HIGHWAYS
TOWN OUTHOLD, NEW YORK
Received by the Town Clerk
/-,. .;1/- or
Date
/-<.~ ~- OJ
Date
Permit Issued
102. .2/. or
Permit No.
ISI
Note: Pennit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39
Page 2 of 3
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KEYSPAN/6tlf
REQUEST FOR STREET OPENING PERMIT.
Fc.6111.4
PERMIT
NO.
lOCATION
~eA$ON FOR
OPENING
W.OJPA
. NO.
REQUESTED
BY
APPROVED
o STATE
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DEPARTMENT
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