HomeMy WebLinkAbout15 4th St
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Received $ 45.00
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Soul hold
Soulhold, New York 11971
Phone: 631-765-1800
RECEIPT #146
1 - Permits on 12/1 0/2001 .
Thank you.
FileNo.
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TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
Permit No.
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 Southold, Suffolk County, New York, aod otber
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 authorlzed inspectors to make necessary inspections ortbe
job site.
Print or TvDe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - mCKSVlLLE. NY 11801
Name of Applicant Address
2) Patricia Gilchrist - 15 4" St. - New Suffolk
Name of Owner of Premises
Address
3) ODeD & restore a bell bole on the west side I!:rass area 8ooroximatelv 330 feet south of Jackson Street in New
Suffolk.
Work Description and Location (Street Number, 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 No.
of plica
12-04-01
Date
5) a) Attach plot plan showing location of proposed excavation aod 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 applieation made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
TlOOI09354
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 applications and permits: Basic Application Fee................. $25.00
AI. -I-/Service Connections excavations @ $20.00 = $ 20.00
No.
A2. _/ Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 I.f. ~ $10.00
1.[ @$O.IO~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 1.[ ~ $30.00
1.[ @ $0.30 ~ $
Additional
D. Excavations 5' in depth and over:
0-100 I.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
permit.
* * *
TOTAL COST $45.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPERINTENDENT OF HIGHWAYS
TOWN OF SOUTH OLD, NEW YORK
()~{'~U~"'d' /Ml LlM/ f/,.,'1 ~~
Raymond ~. Jacobs
Received hy the Town Clerk
Permit Issued l:l /r4' h (
.
I ;J/lb/or
Date
(2-/0' (),
Date
Permit No.
/ c.j t,
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
DEC..-O.4' O! (TUE) 09 42
FC,6111,4
PI:RMIT
NO,
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
3C GAS DESiGN PATCH
~S~515 7585:35
KEYSPAN/6A.f
REQUEST FOR STREET OPENING PERMIT
O SUFFOLK rv1 <C'" .-JI
COUNTY ~ ...J() Ll THo OJ
DATE
PO./ /) 9.J,Sf/.. 12/1/21)D/
~ ~ElX" 3.30" S c .7~k'soJ
o STATE
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~ J/ DEPARTMENT
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