HomeMy WebLinkAbout1647 Peconic Bay Blvd Town Of Southold
P.O Box 1179 /
Southold, NY 11971
* * * RECEIPT * * *
Date: 05/03/04
Transaction(s):
1 Permits
Receipt#:
3107
Subtotal
$45.00
Check#: 3107
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 93249
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~#T100380602
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 d~scribed. The applicant agr~s 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. - HICKSVILLE~ NY 11801
Name of Applicant
2) 1647 Peconic Bay Blvd., Laurel
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
5)
Address
Address
Peconic Bay Blvd. - 4'X4' bellhole e/s of Willow Lane~ 85' s/o Peconic Bay BIvd.~ Laurel, for a gas service to
#1647 Peconic Bay Blvd.
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Y~s No X
*If yes, other Town p~rmlts may be r~luired.
Plumber's License No.
Other T~a~ License N.°'
~ ' Si gnat ~r4e-~0~-o4Ap~ic~lt 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 may not commence before issuance ora Highway Excavation Permit
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: $
ll) Remarks:
Completion Date
D-39
Page 1 of 3
T100380602
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) Secuhty:
a)
Surety Bond or Certified Check provided in the total amount
orS
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for am~lications and permits: Basic Application Fee ................. $25.00
Al. 1 /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 I.f. -- $10.00
I.f. ~ $0.10 - $
Additional
Excavations 18" in depth to 5' in depth:
0-100 l.f. = $30.00 =
~ l.f. @ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-I00 I.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
Authorization is h~reby 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.
S ENT OF.IG '^¥S
Date
Received by the Town Clerk -"~'-/3/O(~
Permit Issued ~- ~.~/0 q" Date
· . Permit No. .~a2 ~
Note: Permitexpiresone(I)year from Dateoflssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
Permit must be available for inspection.
D-39 Page 2 of 3
P~T APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
4/20/2004 11:~.5:25 AM
1647 PECONIC BAY BI,VD
LAUREL
T10~0~02
VILLAGE O~F
srP. EET: PECONIC BAY BLVD ROW
~[IIlFACE:
Macadam Road
Iteu~e NO.
1647
Bell Hole
WILLOW LANE