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HomeMy WebLinkAbout260 Peconic Bay BlvdTown Of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 02/02/04 Transaction(s): 1 Permits ReceiptS: 2708 Subtotal $45.00 Check#: 2708 Total Paid: $45.00 Name: Keyspan, Energy - Gas Cont Dept 175 E Old County Rd Hicksville, NY 11801 Clerk ID: LINDAC Internal ID: 88798 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£#T100358240 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 2) 260 Peconic Bay Blvd., Laurel Name of Owner of Premises 3) 4) Builder's License No. Electrician's License No. s) Address Address Peconic Bay Blvd. - hellhole sis Peconic Bay Blvd., 400' e/o Laurel Lane, Laurel~ to install a gas service to #260 Work Deseription 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. Plumber's License No. Other Tra~'~s License No. - fi ' rSignat~re d~Appli~tant' U °l~t'°e~ 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 maynoteommencebeforeissuanceofaHighwayExcavationPermit 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: $ Il) Remarks: Completion Date D-39 Page I of 3 T100358240 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. 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 l.f. ~ $0.10 = $ Additional Excavations 18" in depth to 5' in depth: 0-100 l.f. = $30.00 - __ 1.f. @ $0.30 = Additional D. Excavations 5' in depth and over: 0-100 I.£ = $50.00 l ff. ~ $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. SUPERINTENDENT OF HIGHWAYS TO'v~"'~-~ATHOLD, NEW yORK k ~eter W~. Ham~ (~ ~89 Received by the Town Clerk I! Date Note: Permit expires one (I) year from Date of Issnance 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 PF~I~IIT APPLICATION SKI~TCH DATE: LOCATION: TOWN: WORK ORDER: 1.,"23/~004 12:0~:45 PM 260 PECONIC BAY BLVD LAUREL T1003~:S~40 VILLAGE ©P ~O55 STREET: LAUREL LN SURFACE: I-Ie~eN~ ~0 ~ x ~t' Bell Hole PECONIC BAY BLVD