HomeMy WebLinkAbout260 Mayflower Rd
Key, Span Energy
448 East Main Street
Patchogue, NY 11727
Received $ 144.00
ELIZABETH A. NEVILLE, TOWN CLERK
Town of Southold
Southold, New York 11971
Phone: 631-765-1800
RECEIPT #143
1 - Permits on 11/26/2001.
Thank you.
Perimt No. 1,/3
FileNo. /1/3
TOWN OF SOUTHOLD
IDGHWAYDEPARTMENT
Peconic Lane
Peconic, New York 11958
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Soutbold for the issuance 0
an Excavation Permit pursuant to Chapter 83 ortbe Code oftbe 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 authorized Inspectors to make necessary inspections of the
job site.
Print or Tvne
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - mCKSVlLLE. NY 11801
Name of Applicant Address
2) 260 Mayflower Road
Name of Owner of Premises
Address
3) Onen & restore a bell hole & 10' trench in the east side naved area. then a 320' trench north in the east side
erass area in Mattituck.
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) BuUder's Llceuse No.
Plumber's License No.
Electrician's License No.
=._,.u_.~
9A~ dl~.r~
Sign re \\pplic t
11- 9-01
Date
a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or area~ 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
by the Town Clerk.
6) Tax Map: Section
. Block
,Lot
7) Starting Date:
Completion Date:
8) Work Schedule:
Phase ComnletioD Date
Excavation. ...... ..................... ................... ..........................
Fae111ty Installation.. ...... ........ ............ ....... ....................... .....
Backfill & Compaction..... ......... ...... ..... ....... ......... ................
Pavement Replacement.... ... ............... ...... .... ...... ..... .......... ....
9) Under whlcb authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
TlOOI05031
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 $50,000 property damage.
13) Securitv:
a)
b)
Surety Bond
nf$
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. ---L-/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 1.f. ~ $10.00
If.@ $0.10 ~ $
Additional
C. Excavations IS" in depth to 5' in depth:
0-100 1.f. ~ $30,00
230 If. @ $0.30 ~ $ 69.00
Additional
D. Excavations 5' in depth and over:
0-100 1.f. ~ $50.00
1.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 $144.00
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 OUTHOLD, NEW YORK
eP
Raymond L. J
Received by the Town Clerk / / - d (.,. -0 (
Date
Permit Issued / r - OJ&, -0 ( Permit No.
(/- ?--'-O (
Date
IY3
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
O 0 ,NASSAU 0 SUFFOLK
~G-8111,1 ST,ATE COUNTY COUNTY
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~EASON FOR
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