HomeMy WebLinkAbout16600 Mattituck RdTOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Ref.#T100267434
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 sit~
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE~ NY 11801
Name of Applicant
2) 16600 Mattttuck Road~ Mattituck
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
$)
Address
Address
Mattituck Road - a 4'X4' bellhole on Mattituck Road~ 85' w/o Sunset Avenue. Mattituck~ to REPAIR A
GAS LEAK at #16600
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes No __X __
*lf yes, other Town permits may be required.
Plumber's License No.
Other Tf'~de's License No.
// ! Signa[urg~f Apl~c~t
(~/ 02-13-04
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 1 of 3
T100267434
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 lnjury, and $50,000 property damage.
13) Security:
a)
Surety Bond or Certified Check provided in the totaI amount
nfs
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for anolications and hermits: Basic Application Fee ................. $25.00
Al. I /Service Connections excavations ~ $20.00 = $ 20.00
No.
A2. /Additional Excavations same service ~ $10.00 = $
No.
B. Excavations 18" in depth or less:
0-I00 I.£. = $10.00
1.f. ~ $0.10 = $
Additional
C. Excavations 18" in depth to 5' in depth:
0-100 I.f. = $30.00 =
__ 1.f. ~ $0.30 --
Additional
D. Excavations 5' in depth and over:
0-100 l.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.
Received by the Town Clerk 3' [6 "~q
Date
Permit Issued 3° [ ~,' O~
Permit No. ,~ 1 L[
SUPER~T-g~DENT OF HIGHWAYS
Tow or SO T.OLD,
/
Peter W. H~s 0~
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
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 03/16/04
Receipt~: 2783
Transaction(s):
Permits 31 ~{
Permits 3 L.~
Subtotal
$45.00
$45.00
Check#: 2783
Total Paid: $90.00
Name:
Keyspan, Energy
1 Metroteck Center
Brooklyn, NY 11201
Clerk ID: LYNDAB Internal ID: 90965
· FROM
(TUE)FEB 10 2004 20:45/ST. 20:31/NO. 6303606768 P