HomeMy WebLinkAbout1905 Oaklawn AveTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 06/08/04
Transaction(s):
1 Permits
Receipt~:
3248
Subtotal
$45.oo
Check#: 3248
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 95548
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~#T100391317
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 orType
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) Oaklawn Avenue, Southold
Name of Owner of Premises
Address
3)
Oaklawn Avenue - bellhole e/s grass area~ approx. 250' s/o Jernick Lane, Southold~ to install a gas service
to house #1905
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.
No X
4) Builder's License No.
Electrician's License No.
Plumber's License No.
Other Tra~ License No.
/ / t/ Signature of~ppli~nt~
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 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 .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Pagelof3
T100391317
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) 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
Al. 1 /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 1.£ = $10.00
1.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.fi = $30.00 =
__ l.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 I.fi = $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 $45.00
Authorization is hereby granted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk ~/7/
Permit Issued ~/¢ ~]~ Date Permit No.
SUPEJ?AI:,/..~ENDENT OF HIGHWAYS
TO}~q OF ~OUTHOLD, Ng]$t/YORK
[Petcr W. }Jarris q
$/3/0¢
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
KEYSPAN
REQUEST FOR STREET OPENING PERMIT
W.O,IPA
NO.
REQUESTED
BY
APPROVED
FOREMAN"
DEP.~RTMENT
GAS CONSTR. MAINT. & SERVICES
DATE OF
o~..G ,~,~
DIVISION
DATE
N