HomeMy WebLinkAbout1815 Village Ln~sTOWn Of Southold
P.O Box 1179
outhold, NY 11971
* * * RECEIPT * * *
Date: 07/26/04
Transaction(s):
1 Permits
Receipt#:
3480
Subtotal
$45.00
Check#: 3480
Total Paid:
$45.00
Name:
Keyspan, Energy- Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 98726
20/07 '04 MON 14:55 FAX 631 765
SOUTHOLD TOWN CLERK
*** TX REPORT
~ 001
TRANSMISSION OK
TX/RX NO
CONNECTION TEL
CONNECTION ID
ST. TIME
USAGE T
PGS. SENT
RESULT
0736
915165454474
26/07 14:53
01'33
5
OK
ELI.7_.o.I~ETH A. NEVILLE
TOWN CLEP. K
REOIS~ OF VITAL STATISTICS
MARRIAOE OFFICI~K
I~ZCORDS MANAGEMENT OFFICER
FP,~EDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
P,O, Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
OFFICE OF Tr~. TOWN CLEI~ Tov*rN OF SOUTHOLD
FAX ~.4NS1VIITTAL
To:
From:
Dated:
Re:
Janet Mitchell - Keyspan
Linda J, Cooper, Deputy Town Clerk
July 27, 2004
Excavation Permit for 350 Skunk Ln
Number of Pages (including cover): 5
If total transmittal is not received, please call 631-765-1800.
COIVI~NTS:
Permit 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£#T100400657
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 to make necessary inspections of the
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVH ~!~E~ NY 11801
Name of Applicant Address
2) 1815 Village Lane~ Orient
Name of Owner of Premises Address
3) Villaee Lane - 4'X4' bellhole on e/s Village Lane~ ~ i/o Fletcher Street~ Orien~ for the repair of a gas
at #1815
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
4) Builder's License No.
Electrician's License No.
Plumber's License No.
No X
5) a) Attachpl~tplansh~wingl~cati~n~fpr~p~sedexcavati~nandrelati~nshipt~adj~iningpremises~r
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 Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
il) Remarks:
Completion Date
D-39
I~age I of 3
T100400657
12) Insurance Coverage: (At~ach 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 applications and permits: Basic Application Fee ................. $25.00
Al. I /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.~ ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. = $30.00 =
__ l.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 1.f. = 5;50.00
I.f. ~ 5;0.50 = $
Additional
No.
Additional
Utility Repair Excavations ~ 5;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 ~s45.00
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
Permit No. ~ .fit/
S UPE~.RII0,ff~DENT OF HIGHWAYS
TO/WN OF S~.~UTHnOLD, NE.W/YORK
- Pet.e~,W. H~m-~-O
/, Date/
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
PEW_MIT APPLICATION SKETCH
DATE:
LOCATI ON:
TOWN:
WORK ORDER:
7f20~2~4 11:43:3/{ A_M
1815 VILLAGE LN
ORIENT
T100400~7
VILLAGE OF
(~OSS S1REET: FLETCHER. ST
SURFACE:
Ivla~aclam P~ad
I-~e NO.
1815
4 x 4' Bell Hol~
VILLAGE LN