HomeMy WebLinkAbout545 Country Club Dr
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Received $ 45.00
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, NewYor1< 11971
Phone: 631-765-1800
RECEIPT #148
1 - Permits on 12/14/2001.
Thank you.
Permit No. / ~!
FileNo. / J( 8
Ref.#T100113332
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
APPLlCATIONIPERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance
an Excavation Permit pursuant to Chapter 83 of the Code of the Town orSonthold, 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) John Grlmm- 545 Country Club Dr. - Cuteboeue
Name of Owner of Premises
Address
3) ODeD & restore a bell hole in the north side I!r8SS area 3ooroximatelv 500 feet west of Mones Lane.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located witbin 75 feet of tidal wetlands? *Yes
*If yes, otber Town permits may be required.
No
-"
4) Builder's License No.
Plumber's License No.
Electrician's License No.
re 0 pplic
12-10-01
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 tbe Town Clerk.
6) Tax Map: Section
. Block
. Lot
7) Starting Date:
Completiou 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
#T100113332
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Departtnent:
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 oennits: Basic ADDlication Fee................. $25.00
AI. ~Service Connections excavations @ $20.00 ~ $ 20.00
No.
Al. --'Additional Excavations same service@ $10.00 ~ $
No.
B. Excavations 18" in depth or less:
0-100 l.f. ~ $10.00
l.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0- 100 I.f. ~ $30.00
l.f. @ $0.30 ~ $
Additional
D. Excavations 5' in depth and over:
0-100 l.f. ~ $50.00
l.f. @ $0.50 ~ $
Additional
Utility Repair Excavations @$1O.00= $
E.
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 $45.00
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.
Received by the Town Clerk / tilJ/ --I/o (
JIIJ) I/Date
Permit Issued r--r<J 1,,/1'11"1 Permit No.
.
ENT OF HIGHWAYS
SOUTHOLD, NEW YO
dl
11---- )
Date
t<lP
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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KEYSPAN/(fA.r
ReQUEST FOR STREET OPENING PERMIT
FC~1l1.4
PERMIT
NO.
LOCATION C()/AV!l.y Club);4,. -
REASON FOR
OPENING MDolt~ ,J.t:.'
W.OJPA
NO.
REQU~STED ~ ,j DEPARTMENT
BY ...Je..HU7Z- GAS CONSTR. . L ,,%.)
o STATE
o
NASSAU
[M' ~p' t1~ $~)
DATE
/2/e/2.00/
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12 /z. 7 /2.t>>1
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