HomeMy WebLinkAbout100 Bray AveTown Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 02/05/04
Transaction(s):
Permits
ReceiptS:
2735
Subtotal
$45.00
Check#: 2735
Total Paid:
$45.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksville, NY 11801
Clerk iD: LINDAC Internar ID: 89022
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
ReL#T100358435
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) 100 Bray Avenue, Laurel
Name of Owner of Premises
Address
3)
Bray Avenue - bellhole w/s approx. 85' s/o 6th Street~ Laurel, to install a gas service to #100
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.
Plumber's License No.
$)
Electrician's License No. Other T~
//\ //Signature o~
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 maynotcommencebeforeissuanceofaHighwayExcavationPermit
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:
Page I o13
T100358435
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 total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: 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:
0-1001.f. = $30.00 =
__ 1.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 ~ $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 ~his apvlication.
Received by the Town Clerk ~ ~/~O~5'/c9 ~
Date
Permit Issued o~/,.~/D .q,t Permit No. q,~d~
SUP~X~'I~ENT OF HIGHWAYS
TO/WN OF S~)[ITHO~D, NEW/]~J~)RK
Peter W~larris 0
/ ' ~Date
Note: Permit expircs one (l) year from Date oflssuance. Nowork tostart without48 hour noticetothe Superintendent of Highways.
Permit must be available for inspection.
D-39 Pagegof3
JAN-29-2004 15:05
PAN GAS CONSTR
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