HomeMy WebLinkAboutBay Shore RdTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 05/27/04
Transaction(s):
1 Permits
ReceiptS:
3190
Subtotal
$90.00
Check#: 3190
Total Paid:
$90.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 94708
File No. ~
TOV~T OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100352458
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 or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILI,I~; NY 11801
Name of Applicant Address
2) Bav Shore Road Southold
Name of Owner of Premises
Address
3)
Bay Shore Road - two 3'X3' bellholes on the wis of Bay Shore Road in the m~cad~rn~ approx. 98' and 1550'
resnectively n/o Island View Lane for the purpose of doing work on the sas main Csee sketch for details)
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction ocated within 75 feet of tidal wetlands~ *Yes
*If yes, other Town permits may be required.
No X
4) Builder's License No.
Plumber's License No.
Electrician's License No.
~/ Signatm'e o~f~?plic~t ~
0S~2at'0e4
5) a) At~ach 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) 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 .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page 1 of 3
T100352458
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 avvlications and permits:
Al. 1
No.
A2.
No.
Basic Application Fee ................. $25.00
/Service Connections excavations ~ $20.00 = $ 20.00
/Additional Excavations same service @ $10.00 = $
B. Excavations 18" in depth or less:
0-100 1.f. = $10.00
I.f. @ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. = $30.00 =
~ 1.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 l.f. = $50.00
I.£ @ $0.50 -- $
Additional
No.
Additional
Utility Repair Excavations @ $I 0.00 -- $
Repairs same service ~ $5.00 = $
F. Notice to public utilities proof must be provided and at~ached to this application prior to issuance of
permit.
TOTAL COST CftY
KEYSPAN ENERGY DELIVERY in accordance with this application.
Received by the Town Clerk ~'/~ 7//~'~
Permit Issued ~q'/,3 '~'/O ~ Date Je:~ ,~
Perm/t 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
L OF HIGHWAYS
D, NEW
Peter W. Harris 0
/ Date /
10/2/0
coRRosIoN~coNTRoL WORK ORDER~ISTRUCTION
'/, ~' 0 ~c{ ~ 580-7_ ~c¢.. ¢:~¢_.LU /
VILLAGE: &OO~g OL~ STREET:
TOWN OF: SOdf~OLb ~Y &MO~E
M~IMO NUMBER: COST CENTER: PROJECT. ASK NUMBER: MAP NUMBER:
RELEASE TO CONSTUCTION: CORROSION CONTROL BONDED SECTIONS: GOM&S AREA: CORROSION AREA:
INSTALLING PERSONNEL: RECORD ALL ACTIVITIES ASSOCIATED WITH THIS WORK ORDER ON REVERSE SIDE
o ?E,,I~dGS N f
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