HomeMy WebLinkAbout801 Traveler St
Permit No.
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1'-10
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
FileNo.
APPLlCATION/PERMIT FOR HIGHW AY 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 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 Tvoe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. -175 E. OLD COUNTRY RD. - mCKSVILLE. NY 11801
Name of Applicant Address
2) 801 Traveler St. - Southold
Name of Owner of Premises
Address
3) ODeD & restore a bell hole s/s oaved area & a 25' trench north & 75' west in navement then 190' in I!rass on
the sls in Southold.
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.
?-~~",e
1I-12-()1 .
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
hy the Towu Clerk.
6) Tax Map: Sectiou
,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 applicatiou made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of3
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 $50,000 property damage.
W.O.#T100103101
13) Securitv:
a)
b)
Surety Bond
of$
Maintenance Bonded provided:
or Certified Check
provided in the total amount
2 years or
3 years
14) Fees for aoolications and oermits: Basic Aoolication Fee.............. ... $25.00
AI. ~/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.f. @ $0.10 ~ $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. ~ $30.00
190 1.f. @ $0.30 ~ $57.00
Additional
D. Excavations 5' in depth and over:
0-100 I.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 $132.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSP AN ENERGY DELIVERY in accordance with this application.
SUPERINTENDENT OF HIGHWAYS
TOWN OUTHOLD, NEW YORK
/f~ I S--O(
Date
Received by the Town Clerk
Date
Permit Issued
Permit No.
11ft>
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permil must be available for inspection.
D-39
Page 2 of3
NOV.-!1'O:ISJNi !3:;
3J GAS DES:GN JATCH
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KEYSPAN/tI'AS
REQUEST FOR STREET OPENING PERMIT
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PERMIT
NO.
LOCATION
~EASON FOR
OPENING
W.OJPA
NO.
REQUESTED
BY
APPROVED
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FOREMAN
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