HomeMy WebLinkAbout1030 West Creek AvePermit
File NO.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100571167
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, 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 ~ make necessary inspections of the
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant
2) 1030 W. Creek Avenue, Cutchogue
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
Addre~
Address
W. Creek Ave. - bellholes and a 100' trench in the e/s grass area, approx. 200' s/o North Cross,
to install a gas main and a gas service to #1030
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*lf yes, other Town permits may be required.
Plumber's License No.
Other Tra~
/ Signature of Applicant
11-17-05
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) At~ach all other necessar3~ permits and licenses for this project.
e) Work covered by this application may not commence before issuance ora Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section , Block
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authorit~ is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
, Lot
C0mDletion Date
D-39 Page I of 3
T100571167
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 injuw and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
13) Security:
a)
Surety Bond or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. /Service Connections excavations @ $20.00 =
$150.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
I.f. ~ $0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. z $30.00 (100') -- (100' trench)
1.f. ~ .30 =
30.00
Additional
Excavations 5' in depth and over:
0-t00 I.f. = $50.00
l.f. @ $0.50 = $
Additional
NO.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service ~ $5.00 = $
Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST = :$180.00
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.
Received by the Town Clerk I~}~10~~--
Permitlssued L[~_ [~i!l~]O~Date PermitNo. qO~ I
SUPE~-N~I'E-~ENT OF HIGHWAYS
TO OLD, YORK
Not~e: Permit expires one (1) year from Date of Issuance. No work to start w/thout 48 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
PERMIT
NO,
LO~ATION
REA,~ON FOR
..... DATE OF
REQUITEDI DEPAR~E~
Date: 12/02/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt~: 5879
Transaction(s):
1 1
Permits
Reference Subtotal
421 $180.00
Check#:5879
Total Paid: $180.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Intemal ID: 421