HomeMy WebLinkAbout522 Town Creek LnOsTOWn Of Southold
P.O Box 1179
outhold, NY 11971
* * * RECEIPT * * *
Date: 07/07/04
Transaction(s):
1 Permits
Receipt~:
3397
Subtotal
$45.00
Check#: 3397
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 97674
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100400875
APPLICATION 1S 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 CONST1L DEPT. - 175 E. OLD COUNTRY RD. - HICKSVII,I~E. NY 11801
Name of Applicant
2) 522 Town Creek Lane, Southold
Name of Owner of Premises
3)
Address
Address
Town Creek Lane - bellhole on the e/s of Town Creek Lane~ 420' e/o Youngs Avenue for a gan
service installation to #522
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 ~'X~de's License No. / (,
~~l~atur~~
~/ 6-28-04
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 ora Highway Excavation 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
Comoletion Date
D-39 Fage I of 3
T100400875
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) SecuhW:
a)
Surety Bond or Ce*tiffed 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. _l~/Service Connections excavations ~ $20.00 = $20.00
3.2. __/Additional Excavations same service @ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00 -
i.~ @ $O.lO =
Additional
C. 'L~.~tions 18" in depth to 5' in depth:
0-100 lh~$30.00
75 l.f. @2~0 = $22.50
Additional '~
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
1.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 :="$nJ"~rO-''
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.
sur n - ENr OF .IG W^YS
Received by the Town Clerk ~/~9
/7/or Date
Permit Issued '7 Permit No.
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
PERM/T APPLICATION SKETCH
DATE:
LOCAIlON:
TOWN:
WORK ORDER:
6f2W2004 $:~9:12 AM
~22 TOWN CREEK LN
$oLrI~OLD
T100400875
VILLAGE
STREET: YOUNG$ AVE
~JRFACE: ~
54ac~.m Ro~d ~
O
Ho,~e NO.
~0'
4 x 4' BdlHole
TOWN CREEK LN
N
FILE No.537 07/07 '04 07:55 ID: Ffl×: PAGE
Energy Delivery'
Co ./Dept.
Phone #
Fax #
From
Co.
Fax #
of
pagesI~' ~
FILE No.537 07/07 '04 07:55
ID:
FRX:
Permit No.
File No.
TOWN O1~ $O~'t~DLD
H~W~Y D~PA~tTM~NT
Poe. OhiO ~
P~ New York 1195~
(631) 76~3140
APPLICATIO_NfI~ERMIT FOR H~GRVJ~Y ]~XCAV~TION AND
Rzf,~TlO04OfiS'Tg
· n ~s~va~on P~ ~u~nt m ~ ~ ~*be ~ or~* To~ o[ ~u~old, ~uffol~ ~un~, N~ Yor~ ~nd o~her
1) ~,.EYSp&~,~ I~'~R(~Y - ~AS ~.ONS'J'R. D~. - 17S ~ OLD COWRY ~, - ~C~ .Y-~ ~
3) To~ Cre~ Vino- ~lhole on ~e ~s ~ Town Cz~Lane. 420' e/o Youuat Aven~ for a
4) Work D~p~a ~ ~m~n ~r~ Noir, Haml~. C~
(8} h ~e~m Io~ ~tbJn TS f~ of tidal w~7 *Y~. No ~
*lf~, o~ TO~ ~ ~ b~
Plumb~'s Mcase
4) nuUder's ~ceuie No,
El fM~l~ltu's/~lce~$e No,
?)
8)
Oth~' Tta~de's Ljceuse NO.
Date
a) Atinch pbDt plan showing hnflon of p~p~d Reaction nd rda~omhip to a~oJning prtm];~ or
b) A~ ~ o~ uBma~ ~ and II.usu for tbh prM~C
~) Work cov~ by ~b a~p~flon mey n~ ~mm~ b~ore J~u~ce or o ~gbway ~vafion Permit
by the To~ ~k
T~ ~p; S~on . BI~ , , . Lot
S~nI DoM: Co~letJo~ Data;
Work SchMulo:
9) Uud~ which uthtirlty b the apj~c~on mada:
10) Bstlmtod Cost er Propo~d Wor~ S
tx)
PAGE 2/
FILE No.537 07/07 '04 07:55 ID: FAX: PAGE 3/ 4
T100400#?$.
Insul~ce Covera~: (Attach Copy)
Insurance Compaula
Policy#
i~i~e ~et~ ~licy or.ii.ion an filc wilh lhe Hi,way De~nt: . Cover~e r~uir~ ~ended ~o ihe
Bodily }~ ~ ~o~ d~e: $3~,~0/~,~ Bodily Iuj~,
13) S~uritv:
a) Surety Bond or Certified Check provided in ~e total amount
orS
b) Maintanaalc~ Bonded provided: 2 years or 3 years
14) Fl:cs for auplications and permits: ~ ................. $2S.00
Al. { /S~vicaCo~leetionsexoavalions~$20.00=$_ 20.00
No.
A2, /Additional Excavalions sarrm s~vice (~ $ lO,00 = $
No,
Excavations 18" in d~th or less:
0-100 l.f. ~- $10,00
I,f, @ $0,10 - $
Additional
Bxcavations 18" in depth to $' in de[xh:
0-100 I.f, = $30.00 =
~ l.f. ~ $0,30 =
Additional
E. Utility l~,epair Excavations @ S10.00 = $.
No.
~s ~ ~wi~ ~ SS,~ = $.
~digonal
F. No~ ~o public ~lli~es p~f m~t ~ provided ~d a~h~ to ~s ~ppli~fion ~ior to issu~ of
~t.
TOTAL COST ~S.~
Authorlzatioll is hereby ~tmi lo ~m ToWR Cled~ of h'le Town of Southold ~o issue m Highway Excaw~tiee r~m~it ~o:
KEVI~PAN ENERGY DRLII~RR¥ i~ ~cor~e~ ~th this application,
SUPERINTENDENT OF HIGHWAYS
TOW'NOFSOUTHOLD. NEW YOP-..K
D89
Pe;cr W, Harris 0
Date
Rco¢ived by the Town C'lerk
permit I~ued Pen'nit No.
Note: P~ITnlt =xp~ o~o (l) ye. ar from Da~e of [~au&nce. No work to start udth~t 48 hour notice to tho Sup~Tintendent of Highwaya.
Pcr~it must lae awdl~ble for
D-39
FILE No.537 07/07 '04 07:56 ID: FAX: PAGE 4/ a
CoOV Dislribufion:
Highway Dcps,lmont
lnSl~..omr
Applicant
Tow~ Clerk
INSpeCTOR'S RECORD
l~-.ction Da~e
code)
Applicant Not~l
(To Permit Cleft0
I)-39 Page 3 of 3