HomeMy WebLinkAbout1015 Kimberly Lno Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 06/08/04
Transaction(s):
1 Permits
Receipt~:
3256
Subtotal
$45.00
Check#: 3256
Total Paid:
$45.00
Name:
Keyspan, Energy- Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 95547
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.#T100391468
APPLICATION IS HEREBY marie 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 regula~ons 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 Tyne
1) KEYSPAN ENERGY - GAS .CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSV1LLE. NY 11801
Name of Applicant Address
2) KImberi Lane Southold
Name of Owner of Premises
3)
Address
Kimberl¥ Lane - bellhole w/s FAmberly Lane. 200' s/o Roxanne Road~ Southold~ to install a uas service to
house #1015
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.
4) Builder's License No.
Electrician's License No.
No X
Plumber's License No.
Other Tra~ License No.
~// °Z~at4'°e4
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
Facility Installation .............................................................. ..
Baeldlll & Compaction ........................................................
Pavement Replacement ........................................................ .-
Completion Date
9) Under which authority is the application made:
10) EstimatedCostofProposedWork: $
11) Remarks:
D-39 Page 1 of 3
T100391468
12) Insuran~: (AtmchCopy)
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 proper~y 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 annlications and permits: ~on Fee ................. $25.00
Al. 1 /Service Connections excavations @ $20.00 = $ 20.00
No.
A2. /Additional Excavations same service ~ $10.00 = $
B. Excavations 18" in depth oi[ less:
0-1001.£ = $10.00
l.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:
0-1001.f. = $50.00
_ l.f. @ $0.50 = $.
Additional
E. Utility Repair Excavations ~ $10.00 -- $
No.
Repairs same service ~ $5.00 = $
Additional
F. 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.
SLIp~ENT OF HIGHWAYS
Peter W. Harris 0
Received by the Town Clerk ~,/~/~a(
~/~./0 <1e Date Permit No. .ff~
Permit Isaned
Note: ?ermit expires one (l) ye~ from Date of Issuance. Ho work to start without 48 hour notice to the Superintendent of Highways.
permit must he available for inspection.
D-39 Page 2 of 3
DATE:
LoCATI
TOWN:
wORK oRDER:
5f24t200a 11:24:21
1015 KIIv~EP, LY LN
sOUTHOLD
T10~91~5~
pFAO/IIT APPLICATION SKETCH
VILLAGE O~
(~O~ ~rRE£T: ROX~NE RD
~JRFACE:
Macadam
I H~eNO.
1015
Hole
IKIMBERLY LN