HomeMy WebLinkAbout1055 Wells RdTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 04/28/04
Transaction(s):
Permits
Receipt#:
3051
Subtotal
$45.00
Check#: 3051
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 93015
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
ReL#T100377808
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. - HICKSVILLE~ NY 1180!
Name of Applicant
2) 1055 Wells Road~ Laurel
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
5)
Address
Address
Wells Road - 4'X4' bellhole w/s of Wells Road~ 290' s/o Albo Drive~ Laurel~ for a gas service to 01055
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.
Plumber's License No.
Other Tra~Li~cense_ N~.
ff ~Signature of ~pplicO ~
[ / 0'12-04
L/ 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 of a 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: $
11) Remarks:
Completion Date
D-39
Page I of 3
T100377808
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 anvlications 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 l.f. = $10.00
1.£ ~ $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 1.f. = $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.
NDENT OF HIGHWAYS
OUTHOLD, ~l~W YORK
Peter W~-l~xis 0 ,o
Received by the Town Clerk dy//~/~ ~
Permit Issued ~ Permit No.
Not__e: 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
~ PER3~T APPLICATION SI~TCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
4/12~04 11:52:2'/AM
1035 WF_LLS RD
LAUREL
T10~377~08
VILLAGE OF
STREET: ALBO DR.
~IJRFACE:
Macadam R~ad
I-I~e NO.
1055
Bell Hole
WELDS RD