HomeMy WebLinkAboutNew Suffolk Ave (3)Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 02/27/04
Transaction(s):
Permits
Receipt~:
2772
Subtotal
$45.00
Check#: 2772
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internat ID: 90146
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£#T100265708
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 oftbe
job site.
Print or TVDe
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant
2) New Suffolk Avenue, New Suffolk
Name of Owner of Premises
3)
4) Builder's License No.
Electrician's License No.
5)
Address
Address
New Suffolk Avenue- bellhole on New Suffolk Avenue, 110' w/o Bunny Lane, New Suffolk~ to REPAIR A
GAS LEAK
Work Description and Location (Street Number, Hamlet, Cross Street)
(a) Is construction located within 75 feet of tidal wetiands? *Yes No __X __
*If yes, other Town permits may be required.
Plumber's License No.
Other Tr~t~e's License 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 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: $
11) Remarks:
Comnlction Date
D-39
Page 1 of 3
T100265708
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 anolications and oermits: 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:
0-1001.f. = $10.00
I.£ ~ $0.10 = $
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.f. = $30.00 =
__ 1.f. ~ $0.30 =
Additional
D. Excavations 5' in depth and over:
0-100 1.f. = $50.00
I.~ @ $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.
SUPE~N-T'E~ENT OF HIGHWAYS
TOV~'q OF SO~JTHOLD, NEW YORK
Peter W. Harris 0
Received by the Town Clerk
Date 30 7
Permit Issued ~/,~[/0~I" 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
PERMIT APPLICATION SKETCH
DAT~:
LOCA'II ON:
TOWN:
WORK ORDER:
2510f2~04
NEW SUFFOLK AVE
NEW SUFFOLK
TI002~JT05
VILLAGE OF
CROSS SFREET: BI.FNN Y LN
S[]RFACE: '-~
Ivl~hm P,v~d '-~
I-I~e NO.
110' ~
4 x ,~' Be11Hole
NEWSUFFOLK AVE