HomeMy WebLinkAbout2675 Peconic LnPermit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGH-WAY EXCAVATION AND REPAIR
Re£#T100369524
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
4) Builder's License No.
Electrician's License No.
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVH,I,I~. NY 11801
Name of Applicant Address
2) 2675 Peconie Lan Peconic
Name of Owner of Premises Address
3) Peconic Lane -- two hellholes w/s paved areas aonrox. 600' and 620' s/o Middle Road in Peeonic to install
new ~as service and retire the undersized ~¥infino service.
Work De~crlption and Lo~ation (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 fee~ of tidal wetlands? *Ye~ No X
*If y~s, other Town permits may be required.
Plumber's License No.
~a~e's License No. ~
Other
/ ] t/ Signature o~'Appl~an~
/ / 03-12 4
~/ Date
5) a) ARaeh 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 neeessar3, permits and licenses for this project.
e) W~rk c~vered by this app~ieati~n may n~t ~~mmenee bef~re issuance ~f a Highway Exeavati~n 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
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:
13) Security:
a)
b)
T100369524
Bodily injury and prope~7 damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
Surety Bond or Certified Check provided in the total amount
of $
Maintenance Bonded provided: 2 years or 3 years
14) Fees for aoDlications and hermits: Basic Application Fee
Al. 1 _/Service Connections excavations ~ $20.00 = $ 20.00
No.
A2. /Additional Excavations same service @ $I0.00 = $
No.
$25.00
B. Excavations 18" in depth or less:
0-100 I.f. = $10.00
l.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:
0-100 l.f. = $50.00
l.f. ~ $0,50 = $
Additional
No.
Additional
Utility Repair Excavations @ $i0.00 = $
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.
S~NDENT OF HIGHyqAYS
TOWN OF~OUTHOLD, NEW/YORK
' , ~. 89
ter 0
~.9~: Permit expires one (1) year from Date of lssuance. Noworktostartwithout48hournoticetotheSuperintendentofHighways.
Permit must be available for inspection.
D-39 Page 2 of 3
K~AN GAS CONSTR
KEYSPAN
REQUEST FOR STREET'OpPE~'ING PERMIT
PERMIT MIS JO ' ' DATE
REQUESTED { . ] DEPARTME~ IDIVJSION
APPROVEDk I
~I(ETCH
¢Zt, 75
I .
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 03/17/04
Transaction(s):
1 Permits
Receipt~:
2897
Subtotal
$45.00
Check#: 2897
Total Paid:
$45.00
Name:
Keyspan, Energy
1 Metroteck Center
Brooklyn, NY 11201
Clerk ID: LYNDAB Internal ID: 90994