HomeMy WebLinkAbout3550 Grathwohl RdTown OfSouthold
P.O Box 1179
Southold, NY 11971
(631) 765-1800
RECEIPT
#326
06/28/2004
Keyspan, Energy- Gas Cont Dept
175. E' Old County Rd.
Hicksville, NY 11801
Received $ 97.50 for Permits, on 06/28/2004. Thank you for stopping by the Town Clerk's office.
,As always, it is our pleasure to serve you.
Neville
Clerk
Elizabeth A.
Southold Town
Town OfSouthold
P.O Box 1179
Southold, NY 11971
(631) 765-1800
RECEIPT
#326
06/28/2004
Keyspan, Energy- Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Received $ 97.50 for Permits, on 06/28/2004. Thank you for stopping by the Town Clerk's office.
As always, it is our pleasure to serve you.
Neville
Clerk
Elizabeth A.
Southold Town
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 06/28/04
Transaction(s):
Permits
Receipt~:
3328
Subtotal
$45.00
Cash#: 3328
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 96737
Per'mit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peeonic Lane
Peeonic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100398006
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 CONSTR, DEPT. - 175 E. OLD COUNTRY RD. - HICKSVH,Lg,_ NY 11801
Name of Applicant Address
2) 3550 Grathwohl Road, New Suffolk
Name of Owner of Premises
Address
3)
4)
Grathwohl Road - bellhole and a 175' trench in the n/s gradd area~ approx~ 295' n/o Wicks Road
in New Suffolk to install gas main and gas service to #3550
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.
4) Builder's License No.
Electrician's License No.
5)
Plumber's License No.
[Signature o~Appli0an(
6-15-04
Date
a) Attach plot plan showing location of preposed excavation and relationship to adjoining premises or
public streets or areas, and giving a detailed description of layout of excavation.
b) At~ach 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:
Lot
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Comnletion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work:
I1) Remarks:
D-39 Page I of 3
T100398006
12) Insurance Coverage: (AR,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 anolications and hermits: Basic Application Fee ...
Al. _l__/Service Connections excavations ~ $20.00 = $20.00
$25.00
A2. /Additional Excavations same service ~ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00 -
1.f. @ S0.10 =
Additional
Excavations 18" in depth to 5' in depth:
0-I00 l.f. = $30.00
75 1.f. @ $0.30 = $22.50
Additional
D. Excavations 5' in depth end over:
0-100 hf. = $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 = $97.50
Authorization is hereby granted to the Town Clerk of the To,sa of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk ~/~Dat~/0 ct/
Permitlssued ~/~../a PermitNo. ,~1~ ~>
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
3UNZ~4-2~4 0?:24
PERMIT
NO,
LOOA~ON
REASON FOR
OPENING
APPROVED
KEYSPRN GRS CONSTR P.05/05
KEYSPAN
REGUEST FOR STREET OPENING PERMIT
[] STATE [] NASSAU SUFFOLK
. COUNTY
O~ENJNG
~S ~N~TR, MAI~, & SERVICE8 ' DATE
....
TOTR/ P. 05