HomeMy WebLinkAbout3400 Wells AveTown Of Southold
P.O Box 1179
Southoid, NY 11971
* * * RECEIPT * * *
Date: 06/28/04
Transaction(s):
1 Permits
Receipt~:
336O
Subtotal
$45.00
Check#: 3360
Total Paid:
$45.00
Name:
Keyspan, Energy- Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 96739
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
Ref.#T100400303
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 nectssary 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) 3400 Wells Avenue~ Southold
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
Address
Address
Wells Avenue - hellhole n/s ~rass area aonrox. 660' e/o Oaklawn Avenue. Southold. to install a gas service
to house 03400
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No
*If yes, other Town permits may be required.
Plumber's License No.
Other Tra~dP~s~ License No.
Date
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 maynotcommencebeforeissuanceofaHighwayExcavationPermit
by the Town Clerk.
6) Tax Map: Section
7) Starting Date:
8) Work Schedule:
Block , Lot
Completion Date:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
Completion Date
D-39
Page 1 of 3
12) Insurance Covera~e: (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:
13) Security:
a)
b)
T100400303
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, end $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
of $
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 l.f. = $10.00
1.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-1001.f. = $30.00 =
__ 1.f. ~ $0.30 =
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 $45.00
Received by the Town Clerk
/~ /0 Date
Permit Issued ~ ~ ~ Pe~it No.
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.
SUJ~-~ENT OF HIGHWAYS
TOWN OF~.KO1JTHQLD, NEW, YORK
Peter W. Harris 0
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
KEYSPRN GRS CONSTR P,O2
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
STATE ~ NASSAU SUFFOLK
PERMIT
NO.
LOCATION
REASON FOR
OPENING
W.O./PA
NO.
REQUESTED
BY
APPROVED
SKETCH
FOREMAN DATE OF
IOPE.,.o
DEPARTMENT DIVISION
GAS CONSTR, MAINT, & SERVICES
DATE
N
TOTRL P.02