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HomeMy WebLinkAbout3915 Stillwater AveTown Of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 02/27~04 Transaction(s): 1 Permits Receipt~: 2770 Subtotal $45.00 Check#: 2770 Total Paid: $45.00 Name: Keyspan, Energy - Gas Cont Dept 175 E Old County Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID: 90145 f Permit No. f~ ~ File No. __ TOWN OF SOUTHOLD HIGHWAY DEPARTMENT Peconic Lane Peconic, New York 11958 (631) 765-3140 APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR Re£#T100361840 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. - H1CKSVILLE, NY 11801 Name of Applicant Address 2) 3915 Stillwater Avenue~ Cutchogue Name of Owner of Premises Address 3) Sfillwater Avenue - bellhole on n/s Stillwater Avenue~ 250' w/o Track Avenue, Cutchogue~ to install a service to #3915 Work Dtscription 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. Plumber's License No. Electrician's License No. Other Tr~'s License No. // [ t/Signature o~ Applicant Date 5) 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 authority is the application made: 10) Estimated Cost of Proposed Work: $ 11) Remarks: D-39 Page 1 of 3 T1003611M0 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 applications and permits: Basic Application Fee Al. I /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-I00 l.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: O-lO0 l.f. = $50.00 l.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. SU~ENT OF HIGHWAYS T 3T~OLD, NE YORK Peter W. Harris V Date Received by the Town Clerk Date Permit Issued Note: P~it expires one (1) year from Date of Issuance. No work to start ~thout 48 hour notice to the Superintendent of Highways. P~it must be available for inspection. D-39 Page 2 of 3 ~ PF, I~MIT APPLICATION SKETCH DATE: LOCATI ON: TOWN: WORK ORDER: ~$10f2~4 10:59:08 AM 391_5 STILLWATER AVE CUTCHOOUE T10~61:~40 VILLAOE ©i~ CROSS STREET: TRACK AVE SURFACE: Mac~ P,o~d House NO. 3915 ,4' Bell Hole m~ STILLWATER AVE