HomeMy WebLinkAbout2870 Fairway Dr
Date: 01/14/03
Transaction(s):
Town Of South old
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
1 Permits
Cash#: 17246
~~
~:Y
Name:
Key, Span Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk 10: lINDAC
Receipt#:
Total Paid:
17246
Subtotal
$1,090.00
$1,090.00
Internal 10: 68538
'Permit No.
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FileNo.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR ffiGHW AY EXCAVATION AND REPAIR
Ref.#TI00236490
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 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. - HICKSVlLLE. NY 11801
Name of Applicant Address
2) 2870 Fairway Drive, Cutchogue
Name of Owner of Premises
Address
ODen & restore a bellhole on the els of Case's Lane in the Daved area at the Vo Fairwav Drive. missile across to
the nlelc of Fairwav Dr. llrass area then trench a total of 2750' in the e:rass areas of Fairwav Dr. with missile
shots across all road crossinlls of Tee La. Fairwav Dr. to Pathway. Fairwav Dr. to Wood Way. Fairwav Dr (no.
side to so. Side) and Green Wav. All work in Cutchoeue to installe:as main and llas senrices to 3 houses. 2750'
of trench and 12 hellholes
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.
re of Ap
01-06-03
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) 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
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 $50,000 property damage.
Tl00236490
13) Security:
a)
b)
Surety Bond_
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and permits: Basic Application Fee................. $25.00
AI. _12_/Service Connections excavations@ $20.00 ~ $240,00
A2. _/ Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 1.[ ~ $10.00
l.f. @$O.IO~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.[ ~ $30.00
2.650 I. f. @ $0.30 ~ $795.00
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 @ $S.OO = $
Additional
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
. . .
TOTAL COST $1.090.00
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.
ENT OF ~~fo~S
~'~~
Peter W. Harris
o/-/3-()~
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.
0-39
Page 2 of3
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