HomeMy WebLinkAbout1285 Fleetwood RdTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 02/27/04
Transaction(s):
1 Permits
Receipt#:
2773
Subtotal
$45.00
Check#: 2773
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID: 90154
Permit No.
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconie, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
ReL#T100268738
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 11801
Name of Applicant Address
2) 1285 Fleetwood Road~ Cutchogue
Name of Owner of Premises
Address
3)
Fleetwood Road - a 4'X4' bellhole on Fleetwood Road~ 275' e/o Beets Street~ Cutchogue~ to REPAIR A GAS
LEAK at 01285
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.
4) Builder's License No.
Electrician's License No.
5)
Plumber's License No.
Other T~'s Licen? No.~ .
~/ 02-10-04
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 , Block , Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authorily is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
Page I 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)
T100268738
Bodily injury and property 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 aDl~lications and permits: Basic Application Fee
Al. 1 /Service Connections excavations ~ $20.00 = $ 20.00
No.
A2. /Additional Excavations same service ~ $10.00 = $
No.
$25.00
B. Excavations 18" in depth or less:
0-100 l.f. = $10.00
1.f. ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-1001.f. = $30.00 =
__ 1.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 I.£ = $50.00
1.£ ~ $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 applicahon.
S~DENT OF HIGHWAYS
TgWN OF~)UTHO/IrD, NEW y~K
Peter W7 Harris'O
Received by the Town Clerk 4/a~/3c~ Date
Date
Permit Issued e~/a~"//~ ~t Permit 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
PERMIT APPLICATION SI~STCH
DATE:
LOCAT[ ON:
TOWN:
WOI~K ORDER:
2510f2(D4
412~ FLEETWOOD RD
CUTCHOOUE
T10~68738
VILLAGE OF
(ROSS SI'P, EET: BET]'S ST
S[IRFACE: ~
NO.
412~
4 x 4' Bell Hol~
FLEETWOOD RD