HomeMy WebLinkAbout75 Gull Pond Ln
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Received $ 45.00
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #149
1 - Permits on 12/21/2001 .
Thank you.
FileNo.
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TOWN OF SOUTHOLD
IDGHWAYDEPARTMENT
Peconic Lane
Peconic, New York 11958
Ref.#T100116059
Permit No.
APPLICATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways or the Town of Southold for the issuanc
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 autborized inspectors to make necessary inspections orthe
job site.
Print or TVDe
.
I) KEYSP AN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVlLLE. NY 11801
Name of Applicant Address
2) Solomon Haselnuss 75 Gull Pond La.
Name of Owner of Premises
GreeDDort
Address
tW.O.#T1001160591
3) ODen & restore a bell hole on the east side oaved area of Gull Pond La.. aooroxirnatelv 50 feet south of Main
Rd.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 7S 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 No. ~
9AY~ 7rsh
Signat of pUcan
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 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 1 of3
.
TI00116059
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 $50,000 property damage.
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oemtits: Basic Aoolicatlon Fee............. .... $25.00
AI. --L.!Service Connections excavations @ $20.00 ~ $ 20.00
No.
A2. _IAdditional Excavations same service@$1O.00=$
No.
B. Excavations 18" in depth or less:
0-100 I.f. ~ $10.00
1.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.f. ~ $30.00
1.f. @ $0.30 ~ $
Additional
D. Excavations 5' in depth and over:
0-100 1.f. ~ $50.00
I.f. @ $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
perntit
. . .
TOTAL COST $45.00
Authorization is hereby granted to the Town Clerk of the Town of Southald to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPERINTENDENT OF HIGHWAYS
TOWN Q OUTHOLD, NEW YORK
Received by the Town Clerk IOJ. Dl /. 6 (
Date
/2 -~- 01
Date
Permit Issued / J. ~ d (~ ?J (
Perntit No.
/I.fej
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
-,
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F>ERMIT
NO.
LOCATION
REASON FOR
OPENING
W,OJF>A
NO,
REQUESTED
BY
APPROVED
SKETCH
M ;j,J
D STATE
KEYSPAN/6A.f
REQUEST FOR STREET OPENING PERMIT
o
I , vUoJ
O SUFFOLK 1./1
COUNTY ~ $;;",,1f1DI.,'D
DATE
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