HomeMy WebLinkAbout940 Clearview AvePermit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#TI00570956
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of South#Id for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of South#Id, 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 Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant Address
2) 940 Clearview Ave, South#Id
Name of Owner of Premises Address
3) Clearview Ave. - hellhole and a 100' trench in the n/s grass area w/o Breitstadt Ct. to install a
gas main and gas service to 0940. THIS IS A RUSH INSTALLATION - CUSTOMER NO
HEAT
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No X
*If yes, other Town permits may be required.
Plumber's License No.
Other Tra~
Signature of Applieant
11-16-05
Date
$) a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or arca~, and giving a detailed description of la¥ont of excavation.
b) Attach all othcr necessary permits and licenses for this projcct.
c) Work covered by this application may not commence before issnance of n Itighwny Excnvafion Permit
4) Builder's License No.
Electrician's License No.
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 authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
, Lot
Completion Date
D-39 Page I of 3
TI00570956
12) lnsur~ce Coveraee: (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)
Surety Bond or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for anolications and permits: Basic Application Fee
A I. /Service Connections excavations ~ $20.00 =
$150.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00 -
i.f. @ $0. i0 =
Additional
Excavations 18" in depth to 5' in depth:
0-100 Iff. = $30.00 (100') -- (100' trench)
l.f. ~ .30 =
30.00
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
I.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
Permit Issued q[g Date Permit No.
S~NDENT OF HIGHWAYS
T OUTH D, NEW~ ORK
Peter W. Harris
~ Dat]
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 of 3
· ~Ec KEYs.A.
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PERMIT ' HI8 JOB ~ DATE
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Town Of Southoid
P.O Box 1179
Southold, NY 11971
Date: 11/21/05
* * * RECEIPT * * *
Receipt#: 5871
Transaction(s):
1 1
Permits
Reference Subtotal
418 $180.00
Check#: 5871
Total Paid: $180.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LYNDAB Internal ID: 418