HomeMy WebLinkAbout2030 Jockey Creek Dr
Permit No. I Lf /
File No. / t..( I
TOWN OF SOUTHOLD
ffiGHWAYDEPARTMENT
Peconic Lane
Peconic, New York 11958
APPLICATION IS HEREBY made to tbe Superintendent of Highways of the Town of South old for the issuance
an Excavation Permit pursuant to Chapter 83 oftbe Code oftbe 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 oftbe
job site.
Print or TVDe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - mCKSVILLE. NY 11801
Name of Applicant Address
2) 2030 Jockev Creek Dr.
Name of Owner of Premises
Address
3) ODeD & restore a bell hole & 640' trench south on the els of Oaklawn Ave. in 2rass area & a 410' trench west
on Jockev Creek Dr.. in the s/s I!:rass area w/directional drills across the intersections & a bell hole in sit Daved
intersection ofOaklawn Ave. & Wells Rd.
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.
e of
!!:ll...-
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 Scbedule:
Phase Comnletion Date
Excavation -::::=.................................... .............................
Facility Installation...... ......... .............. ...... .......... ........ .... .......
Backfill & CompactioD.........................................................
Pavement Replacement................ ... ........................... .... .......
9) Under wbicb autbority is tbe application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
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W.O.#T100102606
12) Insurance Coverae:e: (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 $50,000 property damage.
13) Security:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic Aoolication Fee................. $25.00
At. ~/Service Connections excavations @ $20.00 = $20.00
No.
A2. ----1-1 Additional Excavations same service @ $10.00 = $10.00
No.
B. Excavations 18" in depth or less:
0-100 1.f. ~ $10.00
1.f. @$0.1O~$
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. ~ $30.00
950 I.f. @ $0.30 ~ $285.00
Additional
D. Excavations 5' in depth and over:
0-100 1.f. ~ $50.00
1.f.@ $0.50 ~ $
Additional
E.
Utility Repair Excavations @ $1 0.00 ~ $
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 $370.00
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 F SOUTHOLD, NEW YORK
Permit Issued
/I //,"/JI
,
11/t5/() (
Date
/r-I.<)"tJ(
Date
Received by the Town Clerk
Permit No.
Ill!
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
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