HomeMy WebLinkAbout415 Wiggins LnTown Of Southold
P.O Box 1179
Southoid, NY 11971
* * * RECEIPT * * *
Date: 07/23/04
Transaction(s):
1 Permits
Receipt~:
3361
Subtotal
$45.00
Check#: 3361
Total Paid:
$45.00
Name:
Keyspan, Energy- Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 98617
Permit No.. ~' '~
File No. f~)~
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100399756
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 oftke
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE, NY 11801
Name of Applicant
2) 41S Wiegins Lane~ Greennort
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
s)
Address
Address
Wiggins Lane - bellhole e/s of Wiggins Lane, 460' s/o North Road, to install a gas service to house #415
Work Description and Location (Street Number, Hamlet, Cross Stree0
(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.
//' S~gnaturL~/ 0~f4 4~plica~j~ ' Date
a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises nc
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
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
Comnletion Date
D-39
Page I of 3
T100399756
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.
13) Seeuritv:
a) Surety Bond or Certified Check provided in the total amount
orS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for anolications and p~mits: Basic Application Fee
Al. I /Service Connections excavations @ $20.00 = $ 20.00
No.
A2. /Additional Excavations same service @ $10.00 = $
No.
$25.00
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. = $30.00 =
__ l.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 1.f. = $50.00
I.£ @ $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 $45.00
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.
Reeeived by the Town Clerk '~ /~.t?/O(-//
Permit Issued ~,~ ~/ Permit No.
SUPERI~I~Ee~ OF HIGHWAYS
TovroF
Peter 5/
/ Date /
Note: Permit expires one (1) year from Date of Issuance. No work to start without 48 hour notice m the Superintendent of Highways.
Permit must be available for inspection.
D-39 Page 2 of 3
DATE:
LOCATI ON:
TOWN:
WORK OP, DER:
6/21/2004 11:52:24 AM
415 WIGGINS LN
GKEF_~OKT
t10~399756
PER1VI/T APPLICATION SKETCH
VILLAGE OF
(:ROSS STREET: NORTH RD
~JRFACE:
Mac~m P~d
H~eN~
~5
z60'
4 x 4' Bell Hole
WIGGINS LN